Basic Information
| Provider Information | |||||||||
| NPI: | 1023217437 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WORMACK | ||||||||
| FirstName: | CASSANDRA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39465 W 14 MILE RD | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483771600 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2205 JOLLY RD | ||||||||
| Address2: | STE. B | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173474085 | ||||||||
| FaxNumber: | 5173474170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 11/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301072467 | MI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208D00000X | 4301072467 | MI | N | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | 4301072467 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5199852 | 05 | MI | MEDICAID |