Provider Demographics
NPI:1033458393
Name:CONCEPCION TY ANCOG, M.D., P.C.
Entity Type:Organization
Organization Name:CONCEPCION TY ANCOG, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONCEPCION
Authorized Official - Middle Name:TY
Authorized Official - Last Name:ANCOG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:246-646-5288
Mailing Address - Street 1:7383 LAHSER RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-4049
Mailing Address - Country:US
Mailing Address - Phone:248-646-5288
Mailing Address - Fax:
Practice Address - Street 1:5528 METROPOLITAN PKWY
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4105
Practice Address - Country:US
Practice Address - Phone:586-795-3232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43014047782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0631036Medicare PIN
MIA78095Medicare UPIN