Provider Demographics
NPI:1720019383
Name:BACK, WILLIAM R (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:BACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30626 FORD RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-1870
Mailing Address - Country:US
Mailing Address - Phone:734-261-9211
Mailing Address - Fax:734-261-8537
Practice Address - Street 1:30626 FORD RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-1870
Practice Address - Country:US
Practice Address - Phone:734-261-9211
Practice Address - Fax:734-261-8537
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIWB006125207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4591495Medicaid
MIN87500003Medicare ID - Type Unspecified
MI4591495Medicaid