Basic Information
| Provider Information | |||||||||
| NPI: | 1578606463 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LURCOTT | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 2799 WEST GRAND BOULEVARD | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139162436 | ||||||||
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| Practice Location | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 2799 WEST GRAND BOULEVARD | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139162436 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207W00000X | 4301072643 | MI | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | RL072643 | 01 | COMMERCIAL-COMMERCIAL NUMBER | OTHER | RL072643 | 01 | CHAMPUS-CHAMPUS | OTHER |