Provider Demographics
NPI:1982796355
Name:REBOCK, MICHAEL DAVID (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:REBOCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28080 GRAND RIVER
Mailing Address - Street 2:208 N
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336
Mailing Address - Country:US
Mailing Address - Phone:248-478-7733
Mailing Address - Fax:248-478-3533
Practice Address - Street 1:28080 GRAND RIVER
Practice Address - Street 2:208 N
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336
Practice Address - Country:US
Practice Address - Phone:248-478-7733
Practice Address - Fax:248-478-3533
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIMR011373208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
020F31144OtherBCBS OF MI
MI323358011Medicaid
MI0M02930003Medicare ID - Type Unspecified
MI323358011Medicaid