MEDICARE: PAUL V DETRISAC MD PC

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

General Provider Information

NPI Number	:	1629277439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAUL V DETRISAC MD PC

Provider Business Mailing Address
First Line	:	PO BOX 998
Second Line	:
City	:	NILES
State	:	MI
Zip	:	49120-0998
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	24 N SAINT JOSEPH AVE
Second Line	:
City	:	NILES
State	:	MI
Zip	:	49120-2263
Country	:	US
Telephone Number	:	269-684-8356
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PAUL V DETRISAC
Credential	:
Telephone Number	:	269-684-8356

Provider Enumeration Date	:	07/12/2007
Last Update Date	:	07/12/2007

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