Provider Demographics
NPI:1548226467
Name:PRATT, CECILLY A (MD)
Entity Type:Individual
Prefix:
First Name:CECILLY
Middle Name:A
Last Name:PRATT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15959 HALL RD STE 104
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-5364
Mailing Address - Country:US
Mailing Address - Phone:586-884-2688
Mailing Address - Fax:586-566-1674
Practice Address - Street 1:15959 HALL RD STE 104
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044
Practice Address - Country:US
Practice Address - Phone:586-884-2688
Practice Address - Fax:586-566-1674
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078472207Q00000X
GA069696208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI464270910Medicaid
MI700E012740OtherBCBSM GROUP NUMBER
MI0N40170Medicare PIN
MII18429Medicare UPIN