Provider Demographics
NPI:1609077783
Name:MICHIGAN VASCULAR ACCESS, PC
Entity Type:Organization
Organization Name:MICHIGAN VASCULAR ACCESS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:248-355-1100
Mailing Address - Street 1:21701 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3713
Mailing Address - Country:US
Mailing Address - Phone:248-355-1100
Mailing Address - Fax:
Practice Address - Street 1:21701 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3713
Practice Address - Country:US
Practice Address - Phone:248-355-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMW0511992086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4697091Medicaid
MIMW051199OtherSTATE LICENSE
MIMW051199OtherSTATE LICENSE
F87919Medicare UPIN