Provider Demographics
NPI:1962497248
Name:PRUSSACK, LAWRENCE B (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:B
Last Name:PRUSSACK
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:6900 ORCHARD LAKE RD
Mailing Address - Street 2:STE 311
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3405
Mailing Address - Country:US
Mailing Address - Phone:248-855-6663
Mailing Address - Fax:248-855-7546
Practice Address - Street 1:6900 ORCHARD LAKE RD
Practice Address - Street 2:STE 306
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3405
Practice Address - Country:US
Practice Address - Phone:248-855-6663
Practice Address - Fax:248-855-7546
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301043881207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2722284Medicaid
F36120009Medicare ID - Type Unspecified
MI2722284Medicaid