MEDICARE: THERESA VETTESE MD

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	207R00000X	Internal Medicine Physician	4301057647	MI
2	207RH0002X	Hospice and Palliative Medicine (Internal Medicine) Physician	4301057647	MI

General Provider Information

NPI Number	:	1316966906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA VETTESE MD

Provider Business Mailing Address
First Line	:	1420 STEPHENSON HWY
Second Line	:	SUITE 400-CREDENTIALING
City	:	TROY
State	:	MI
Zip	:	48083-1189
Country	:	US
Telephone Number	:	248-581-5972
Fax Number	:	248-581-5640

Provider Business Practice Location Address
First Line	:	50 E CANFIELD
Second Line	:	GENERAL MEDICINE AMBULATORY PRACTICE
City	:	DETROIT
State	:	MI
Zip	:	48201-1804
Country	:	US
Telephone Number	:	313-745-4525
Fax Number	:	313-966-7305

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

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	11/08/2013

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