Provider Demographics
NPI:1629240965
Name:SAMUEL J MUCCI M.D.P.C.
Entity Type:Organization
Organization Name:SAMUEL J MUCCI M.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BARC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-283-1115
Mailing Address - Street 1:15590 W 13 MILE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5642
Mailing Address - Country:US
Mailing Address - Phone:248-283-1115
Mailing Address - Fax:248-283-1119
Practice Address - Street 1:15590 W 13 MILE RD
Practice Address - Street 2:SUITE A
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025-5642
Practice Address - Country:US
Practice Address - Phone:248-283-1115
Practice Address - Fax:248-283-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067463174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2406314511OtherBCBSM
MI103269170Medicaid
MI2406314511OtherBCBSM