Provider Demographics
NPI:1841257029
Name:BULLY, ANGELA (MD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:
Last Name:BULLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4160 JOHN R ST
Mailing Address - Street 2:SUITE 804
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2020
Mailing Address - Country:US
Mailing Address - Phone:313-833-1271
Mailing Address - Fax:313-833-1273
Practice Address - Street 1:4160 JOHN R ST
Practice Address - Street 2:SUITE 804
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2020
Practice Address - Country:US
Practice Address - Phone:313-833-1271
Practice Address - Fax:313-833-1273
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057665207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP13720Medicare ID - Type Unspecified
MIG17033Medicare UPIN