Provider Demographics
NPI:1962506527
Name:DETRISAC, PAUL V (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:V
Last Name:DETRISAC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 998
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120
Mailing Address - Country:US
Mailing Address - Phone:269-684-8356
Mailing Address - Fax:
Practice Address - Street 1:24 N ST JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120
Practice Address - Country:US
Practice Address - Phone:269-684-8356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPD043661207RC0200X
IN01032411A207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1508904Medicaid
MION94600Medicare ID - Type Unspecified
B47426Medicare UPIN
MI1508904Medicaid