Provider Demographics
NPI:1417389396
Name:DAVID VANDAM LLC
Entity Type:Organization
Organization Name:DAVID VANDAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DAM
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:248-421-5876
Mailing Address - Street 1:6985 MILLER DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-4725
Mailing Address - Country:US
Mailing Address - Phone:586-264-3500
Mailing Address - Fax:586-264-3495
Practice Address - Street 1:5130 COOLIDGE HWY
Practice Address - Street 2:SUITE 120
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-1001
Practice Address - Country:US
Practice Address - Phone:248-658-0878
Practice Address - Fax:248-435-0930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-02
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704115131367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty