Basic Information
| Provider Information | |||||||||
| NPI: | 1730135492 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESANTIS | ||||||||
| FirstName: | ANNETTE | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1420 STEPHENSON HWY | ||||||||
| Address2: | SUITE 400--CREDENTIALING | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485815974 | ||||||||
| FaxNumber: | 2485815640 | ||||||||
| Practice Location | |||||||||
| Address1: | 18181 OAKWOOD BLVD | ||||||||
| Address2: | SUITE 411 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481245032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134387373 | ||||||||
| FaxNumber: | 3134387375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 11/04/2013 | ||||||||
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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 | 208100000X | AD042312 | MI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 2505035481 | 01 | BCBS | OTHER |