Basic Information
| Provider Information | |||||||||
| NPI: | 1881704682 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESANTIS | ||||||||
| FirstName: | ANGELA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 GREENFIELD RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481201802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135633332 | ||||||||
| FaxNumber: | 3135633342 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 BIDDLE AVE | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481927205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342842026 | ||||||||
| FaxNumber: | 7342848335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 02/13/2014 | ||||||||
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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 | 207RC0200X | 4301052721 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207R00000X | 4301052721 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 297792310 | 05 | MI | MEDICAID | 110H211300 | 01 | MI | BCBS MI | OTHER |