Provider Demographics
NPI:1477523520
Name:COLUCCI, ANTHONY JAMES (DO)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JAMES
Last Name:COLUCCI
Suffix:
Gender:M
Credentials:DO
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Other - Credentials:
Mailing Address - Street 1:28935 ANN ARBOR ROAD
Mailing Address - Street 2:CREDENTIALING/PAYOR CONTRACTING SERVICES
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:734-632-0175
Mailing Address - Fax:734-632-0182
Practice Address - Street 1:15855 NINETEEN MILE ROAD
Practice Address - Street 2:EMERGENCY MEDICINE DEPARTMENT
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-3504
Practice Address - Country:US
Practice Address - Phone:586-263-2601
Practice Address - Fax:586-263-2589
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2012-04-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101010623207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11273954OtherCAQH
MI1477523520Medicaid