Provider Demographics
NPI:1912392275
Name:ANTHONY IACCO MD PLC
Entity Type:Organization
Organization Name:ANTHONY IACCO MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:IACCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-657-2409
Mailing Address - Street 1:3535 W 13 MILE RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6770
Mailing Address - Country:US
Mailing Address - Phone:248-551-9095
Mailing Address - Fax:248-551-9080
Practice Address - Street 1:3535 W 13 MILE RD
Practice Address - Street 2:SUITE 204
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6770
Practice Address - Country:US
Practice Address - Phone:248-551-9095
Practice Address - Fax:248-551-9080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092602208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty