=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992833396
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT EDWARD DEMERCURIO D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 08/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35455 GARFIELD RD STE C
-----------------------------------------------------
City | CLINTON TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48035-2236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-792-5335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35455 GARFIELD RD STE C
-----------------------------------------------------
City | CLINTON TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48035-2236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-792-5335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 5101019059
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MB63411
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------