MEDICARE: SUPAK SOOKKASIKON M.D.

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	4301083253	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5315028426	OTHER	MI	CONTROLLED SUBSTANCE

General Provider Information

NPI Number	:	1649376922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUPAK SOOKKASIKON M.D.

Provider Business Mailing Address
First Line	:	4050 W MAPLE RD
Second Line	:	SUITE 101
City	:	BLOOMFIELD TOWNSHIP
State	:	MI
Zip	:	48301-3148
Country	:	US
Telephone Number	:	248-885-8211
Fax Number	:	248-885-8357

Provider Business Practice Location Address
First Line	:	4050 W MAPLE RD
Second Line	:	SUITE 101
City	:	BLOOMFIELD TOWNSHIP
State	:	MI
Zip	:	48301-3148
Country	:	US
Telephone Number	:	248-885-8211
Fax Number	:	248-885-8357

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

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	02/28/2014

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