MEDICARE: SIYUAN FU M.B.

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1235875964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIYUAN FU M.B.

Provider Business Mailing Address
First Line	:	2799 W. GRAND BLVD HENRY FORD HOSPITAL
Second Line	:
City	:	DETRIOT
State	:	MI
Zip	:	48202
Country	:	US
Telephone Number	:	313-916-1601
Fax Number	:	313-916-2018

Provider Business Practice Location Address
First Line	:	2799 W. GRAND BLVD HENRY FORD HOSPITAL
Second Line	:
City	:	DETRIOT
State	:	MI
Zip	:	48202
Country	:	US
Telephone Number	:	313-916-1601
Fax Number	:	313-916-2018

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2022
Last Update Date	:	09/09/2022

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