Provider Demographics
NPI:1083620074
Name:MCCANN, PETER MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:MATTHEW
Last Name:MCCANN
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 1:26850 PROVIDENCE PKWY STE 150
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1254
Mailing Address - Country:US
Mailing Address - Phone:248-380-8066
Mailing Address - Fax:248-380-8087
Practice Address - Street 1:26850 PROVIDENCE PKWY STE 150
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1254
Practice Address - Country:US
Practice Address - Phone:248-380-8066
Practice Address - Fax:248-380-8087
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301049740207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1735608Medicaid
D72590Medicare UPIN