Provider Demographics
NPI:1619332558
Name:STACHURA, TUMAR
Entity Type:Individual
Prefix:
First Name:TUMAR
Middle Name:
Last Name:STACHURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29728 MONTMORENCY DR
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2138
Mailing Address - Country:US
Mailing Address - Phone:248-470-9496
Mailing Address - Fax:
Practice Address - Street 1:29728 MONTMORENCY DR
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2138
Practice Address - Country:US
Practice Address - Phone:248-470-9496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-18
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1619332558Medicare PIN