Provider Demographics
NPI:1972505303
Name:SACK, BRUCE M (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
Last Name:SACK
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Mailing Address - Street 1:28800 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2981
Mailing Address - Country:US
Mailing Address - Phone:248-932-2500
Mailing Address - Fax:248-932-2506
Practice Address - Street 1:28800 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 250
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2981
Practice Address - Country:US
Practice Address - Phone:248-932-2500
Practice Address - Fax:248-932-2506
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI43010427732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1481490Medicaid
MIB43535Medicare UPIN
MI1630848Medicare ID - Type Unspecified