MEDICARE: LUISE ANN ILLUMINATI 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	207RI0200X	Infectious Disease Physician	4301047490	MI

General Provider Information

NPI Number	:	1912014689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUISE ANN ILLUMINATI M.D.

Provider Business Mailing Address
First Line	:	3924 SHELLMARR LN
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-4055
Country	:	US
Telephone Number	:	248-496-2112
Fax Number	:

Provider Business Practice Location Address
First Line	:	3924 SHELLMARR LN
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-4055
Country	:	US
Telephone Number	:	248-496-2112
Fax Number	:

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

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	11/17/2019

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