MEDICARE: MR. RANDY C STAPISH 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
1	363A00000X	Physician Assistant	RS001463	MI

General Provider Information

NPI Number	:	1659490464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDY C STAPISH PA-C

Provider Business Mailing Address
First Line	:	8623 N TELEGRAPH RD
Second Line	:	SUITE # 1
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-1489
Country	:	US
Telephone Number	:	313-561-4540
Fax Number	:	313-561-9515

Provider Business Practice Location Address
First Line	:	8623 N TELEGRAPH RD
Second Line	:	SUITE # 1
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-1489
Country	:	US
Telephone Number	:	313-561-4540
Fax Number	:	313-561-9515

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

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	07/08/2007

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