Provider Demographics
NPI:1457782450
Name:REGENTS OF THE UNIVERSITY OF MICHIGAN - AMBULATORY CTR FOR VEIN TRTMT
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF MICHIGAN - AMBULATORY CTR FOR VEIN TRTMT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC MEDICAL DIRECTOR FACULTY GRP
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:SPAHLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-936-3568
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:19900 HAGGERTY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1054
Practice Address - Country:US
Practice Address - Phone:734-432-7811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENTS OF THE UNIVERSITY OF MICHIGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-02
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N22140Medicare PIN