Provider Demographics
NPI:1407812464
Name:FERMAGLICH, DANIEL ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ROBERT
Last Name:FERMAGLICH
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:PO BOX 67000
Mailing Address - Street 2:DEPARTMENT 272801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-841-6913
Mailing Address - Fax:517-841-6917
Practice Address - Street 1:110 N ELM AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3571
Practice Address - Country:US
Practice Address - Phone:517-788-6760
Practice Address - Fax:517-788-3029
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086739208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MII49459Medicare UPIN
MIM50940060Medicare ID - Type UnspecifiedWA FOOTE MEMORIAL