MEDICARE: MICHIGAN VASCULAR INSTITUTE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician	5101007182	MI

General Provider Information

NPI Number	:	1093915910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN VASCULAR INSTITUTE PLLC

Provider Business Mailing Address
First Line	:	538 N OLD WOODWARD AVE
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-5375
Country	:	US
Telephone Number	:	248-594-3091
Fax Number	:	248-594-3068

Provider Business Practice Location Address
First Line	:	538 N OLD WOODWARD AVE
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-5375
Country	:	US
Telephone Number	:	248-594-3091
Fax Number	:	248-594-3068

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. GREGORY P. DERDERIAN
Credential	:	D.O.
Telephone Number	:	248-594-3091

Provider Enumeration Date	:	07/19/2007
Last Update Date	:	02/23/2023

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