Provider Demographics
NPI:1073514048
Name:MUCCI, SAMUEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:MUCCI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15590 W 13 MILE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5642
Mailing Address - Country:US
Mailing Address - Phone:248-283-1115
Mailing Address - Fax:248-283-1119
Practice Address - Street 1:15590 W 13 MILE RD
Practice Address - Street 2:SUITE A
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025-5642
Practice Address - Country:US
Practice Address - Phone:248-283-1115
Practice Address - Fax:248-283-1119
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2009-06-29
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
MI067463174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3269170Medicaid
MI3269170Medicaid
MIG28534Medicare UPIN