Provider Demographics
NPI:1093915910
Name:MICHIGAN VASCULAR INSTITUTE PLLC
Entity Type:Organization
Organization Name:MICHIGAN VASCULAR INSTITUTE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:P
Authorized Official - Last Name:DERDERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-594-3091
Mailing Address - Street 1:538 N OLD WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-5375
Mailing Address - Country:US
Mailing Address - Phone:248-594-3091
Mailing Address - Fax:248-594-3068
Practice Address - Street 1:538 N OLD WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-5375
Practice Address - Country:US
Practice Address - Phone:248-594-3091
Practice Address - Fax:248-594-3068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010071822086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty