Provider Demographics
NPI:1922215201
Name:ANGELA BULLY M.D., P.L.L.C.
Entity Type:Organization
Organization Name:ANGELA BULLY M.D., P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-833-1271
Mailing Address - Street 1:4160 JOHN R ST
Mailing Address - Street 2:SUITE 804
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2020
Mailing Address - Country:US
Mailing Address - Phone:313-833-1271
Mailing Address - Fax:313-833-1273
Practice Address - Street 1:4160 JOHN R ST
Practice Address - Street 2:SUITE 804
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2020
Practice Address - Country:US
Practice Address - Phone:313-833-1271
Practice Address - Fax:313-833-1273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057665207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104357008Medicaid
MI1841257029OtherINDIVIDUAL NPI #
MI4301084811OtherPROVIDER LICENSE #
MIP61277OtherBLUE CARE NETWORK
MI1108235671OtherBLUE CROSS BLUE SHIELD
MI1366536088OtherINDIVIDUAL NPI #
MI4301057665OtherPROVIDER LICENSE #
MIP61277OtherBLUE CARE NETWORK
MI=========OtherEIN OR TAX ID#
MII127186Medicare UPIN
MI4301057665OtherPROVIDER LICENSE #
MIP13720001Medicare ID - Type UnspecifiedMEDICARE MEMBER #
MIP61277OtherBLUE CARE NETWORK