MEDICARE: ALFONSO ACOSTA 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	207Q00000X	Family Medicine Physician	4301064369	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1106335602	OTHER	MI	BC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	P00193884	OTHER		PALMETTO GBA
4	143552	OTHER	MI	GREAT LAKES

General Provider Information

NPI Number	:	1629072038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALFONSO ACOSTA MD

Provider Business Mailing Address
First Line	:	PO BOX 250433
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48325
Country	:	US
Telephone Number	:	586-929-0842
Fax Number	:	248-366-0065

Provider Business Practice Location Address
First Line	:	7173 ILANAWAY DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48324
Country	:	US
Telephone Number	:	586-929-0842
Fax Number	:	248-366-0065

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

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	09/13/2007

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