Provider Demographics
NPI:1124001177
Name:SYLWESTRZAK, MARY SUE J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY SUE
Middle Name:J
Last Name:SYLWESTRZAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY SUE
Other - Middle Name:JENKINS
Other - Last Name:SYLWESTRZAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:33200 W 14 MILE RD
Mailing Address - Street 2:STE 130
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3549
Mailing Address - Country:US
Mailing Address - Phone:248-855-4144
Mailing Address - Fax:248-855-9158
Practice Address - Street 1:33200 W 14 MILE RD
Practice Address - Street 2:STE 130
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3549
Practice Address - Country:US
Practice Address - Phone:248-855-4144
Practice Address - Fax:248-855-9158
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053077208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2886572Medicaid
MI3506337132OtherBLUE CROSS/BLUE SHIELD OF MI
F28229OtherHAP INSURANCE PLAN
F28229OtherHAP INSURANCE PLAN