Basic Information
Provider Information | |||||||||
NPI: | 1790704062 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | DENISE | ||||||||
MiddleName: | ROSE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GALLAGHER | ||||||||
OtherFirstName: | DENISE | ||||||||
OtherMiddleName: | ROSE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | P.A. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 27483 DEQUINDRE RD | ||||||||
Address2: | SUITE 314 | ||||||||
City: | MADISON HEIGHTS | ||||||||
State: | MI | ||||||||
PostalCode: | 480713491 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2485476600 | ||||||||
FaxNumber: | 2485475696 | ||||||||
Practice Location | |||||||||
Address1: | 27483 DEQUINDRE RD | ||||||||
Address2: | SUITE 314 | ||||||||
City: | MADISON HEIGHTS | ||||||||
State: | MI | ||||||||
PostalCode: | 480713491 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2485476600 | ||||||||
FaxNumber: | 2485475696 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 07/09/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601004747 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 700H217350 | 01 | MI | BLUE SHIELD | OTHER | 1790704062 | 05 | MI |   | MEDICAID |