Provider Demographics
NPI:1972806594
Name:DOMENICO S AUSIELLO MD PC
Entity Type:Organization
Organization Name:DOMENICO S AUSIELLO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/BILLING
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-754-6949
Mailing Address - Street 1:200 S FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-1740
Mailing Address - Country:US
Mailing Address - Phone:616-754-6949
Mailing Address - Fax:616-754-1062
Practice Address - Street 1:200 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-1740
Practice Address - Country:US
Practice Address - Phone:616-754-6949
Practice Address - Fax:616-754-1062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0590023OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI2751016Medicaid
MI05900238012Medicare PIN
MI0590023OtherBLUE CROSS BLUE SHIELD OF MICHIGAN