MEDICARE: DR. MARY ANNE PURTILL 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	2086S0127X	Trauma Surgery Physician	4301075397	MI
2	208600000X	Surgery Physician	G076836	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZP4310Z	OTHER	CA	MEDICARE ID - STANFORD SURGERY DEPT

General Provider Information

NPI Number	:	1831192483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY ANNE PURTILL M.D.

Provider Business Mailing Address
First Line	:	PO BOX 67000
Second Line	:	DEPARTMENT 272801
City	:	DETROIT
State	:	MI
Zip	:	48267-2728
Country	:	US
Telephone Number	:	517-817-7605
Fax Number	:	517-817-7606

Provider Business Practice Location Address
First Line	:	1100 E MICHIGAN AVE
Second Line	:	STE 201
City	:	JACKSON
State	:	MI
Zip	:	49201-1847
Country	:	US
Telephone Number	:	517-817-7605
Fax Number	:	517-817-7606

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	03/14/2013

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