Provider Demographics
NPI:1457437469
Name:SALLACH, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:SALLACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1701 SOUTH BOULEVARD E
Mailing Address - Street 2:SUITE 390
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-6117
Mailing Address - Country:US
Mailing Address - Phone:248-293-0055
Mailing Address - Fax:248-293-3348
Practice Address - Street 1:1701 SOUTH BOULEVARD E
Practice Address - Street 2:SUITE 390
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-6117
Practice Address - Country:US
Practice Address - Phone:248-293-0055
Practice Address - Fax:248-293-3348
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301068052207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4821129Medicaid
MI4821129Medicaid
MI0F37182Medicare PIN
MII19966Medicare UPIN