MEDICARE: AMERICAN ACCESS CARE OF DETROIT LLC

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	2085R0204X	Vascular & Interventional Radiology Physician

General Provider Information

NPI Number	:	1508128190
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMERICAN ACCESS CARE OF DETROIT LLC

Provider Business Mailing Address
First Line	:	182 INDUSTRIAL RD
Second Line	:
City	:	GLEN ROCK
State	:	PA
Zip	:	17327-8626
Country	:	US
Telephone Number	:	717-759-6739
Fax Number	:	717-235-4024

Provider Business Practice Location Address
First Line	:	33464 SCHOENHERR RD
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48312-6314
Country	:	US
Telephone Number	:	586-978-4580
Fax Number	:	586-978-4589

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	RONALD H. RODGERS JR.
Credential	:
Telephone Number	:	717-759-6739

Provider Enumeration Date	:	06/11/2012
Last Update Date	:	05/31/2013

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