Basic Information
| Provider Information | |||||||||
| NPI: | 1689291270 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THERIAULT | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21400 E 11 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480811566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864984400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 468 CADIEUX RD | ||||||||
| Address2: | |||||||||
| City: | GROSSE POINTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482301507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134731000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2020 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4351046043 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.