Basic Information
| Provider Information | |||||||||
| NPI: | 1518966316 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARSACK | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | HILDA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 E MAPLE ROAD | ||||||||
| Address2: | SUITE 400- CREDENTIALING | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005276266 | ||||||||
| FaxNumber: | 3135768381 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 JOHN R ST | ||||||||
| Address2: | KARMANOS CANCER CTR MIDLEVELS | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005276266 | ||||||||
| FaxNumber: | 3135768381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 11/23/2016 | ||||||||
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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 | 363L00000X | 4704110630 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 4704110630 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | MM0620333 | 01 | MI | DEA | OTHER |