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NPI Code Detail

MEDICARE: AMY DERECZYK PA-C

MEDICARE: AMY DERECZYK PA-C
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
1363A00000XPhysician Assistant5601003980MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
111712511OTHERCAQH

General Provider Information

NPI Number : 1558349050
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMY DERECZYK PA-C
Provider Business Mailing Address
First Line : 4001 W MCNICHOLS RD
Second Line :
City : DETROIT
State : MI
Zip : 48221-3038
Country : US
Telephone Number : 313-993-1797
Fax Number : 313-993-1271
Provider Business Practice Location Address
First Line : 4001 W MCNICHOLS RD
Second Line :
City : DETROIT
State : MI
Zip : 48221-3038
Country : US
Telephone Number : 313-993-1797
Fax Number : 313-993-1271
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/04/2006
Last Update Date : 05/10/2011

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Directions to “ AMY DERECZYK PA-C” Practice Location

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