Provider Demographics
NPI:1619284320
Name:ROSE DEMCZUK MD PLLC
Entity Type:Organization
Organization Name:ROSE DEMCZUK MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMCZUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-688-8057
Mailing Address - Street 1:7267 TAFT RD
Mailing Address - Street 2:
Mailing Address - City:BRUCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48065-3619
Mailing Address - Country:US
Mailing Address - Phone:248-688-8057
Mailing Address - Fax:248-601-9991
Practice Address - Street 1:7267 TAFT RD
Practice Address - Street 2:
Practice Address - City:BRUCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48065-3619
Practice Address - Country:US
Practice Address - Phone:248-688-8057
Practice Address - Fax:248-601-9991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-02
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058105103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty