Provider Demographics
NPI:1720156268
Name:SULAK, FREDERIC C JR (MD)
Entity Type:Individual
Prefix:
First Name:FREDERIC
Middle Name:C
Last Name:SULAK
Suffix:JR
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:WYANDOTTE HOSPITAL
Mailing Address - Street 2:2333 BIDDLE
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192
Mailing Address - Country:US
Mailing Address - Phone:734-246-7101
Mailing Address - Fax:
Practice Address - Street 1:WYANDOTTE HOSPITAL
Practice Address - Street 2:2333 BIDDLE
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192
Practice Address - Country:US
Practice Address - Phone:734-246-7101
Practice Address - Fax:734-324-3615
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI405362207RC0000X
MI4301405362207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FS405362OtherCHAMPUS-CHAMPUS
060H264410OtherBLUE CROSS-BLUE CROSS
FS405362OtherCOMMERCIAL-COMMERCIAL NUMBER
MI286419010Medicaid