MEDICARE: CAPITAL MEDICAL ASSOC. 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	208VP0000X	Pain Medicine Physician	JG005927	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	055632430	OTHER	MA	BLUE CROSS

General Provider Information

NPI Number	:	1790876241
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPITAL MEDICAL ASSOC. PC

Provider Business Mailing Address
First Line	:	5385 TERENCE CT
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-2555
Country	:	US
Telephone Number	:	248-851-2083
Fax Number	:	248-855-2130

Provider Business Practice Location Address
First Line	:	5385 TERENCE CT
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-2555
Country	:	US
Telephone Number	:	248-851-2083
Fax Number	:	248-855-2130

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JERALD STUART GACH
Credential	:	D.O.
Telephone Number	:	248-851-2083

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	02/28/2013

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