Provider Demographics
NPI:1801152590
Name:TACTICAL MEDICAL PROVIDERS
Entity type:Organization
Organization Name:TACTICAL MEDICAL PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:CIPULLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-773-8923
Mailing Address - Street 1:44471 MIDWAY DR
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-3949
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44471 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-3949
Practice Address - Country:US
Practice Address - Phone:248-773-8923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-06
Last Update Date:2014-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078278261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383369438057OtherCARESOURCE
944326OtherPHCS
1174570428OtherINDIVIDUAL NPI
MI169535OtherUPIN
368970100OtherUS DEPT OF LABOR
MI731258OtherBCBS PIN
MI1174570428Medicaid
MIM74750125OtherMEDICARE
P00378221OtherRAILROAD
MI0994967OtherHEALTH PLUS