Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0102X | Surgical Critical Care | FI076031 | MI |
NPI | 1316078470 |
---|---|
Provider Name | Felicia Ivascu |
First Address | Royal Oak, MI 48073 |
Second Address | Royal Oak, MI 48073 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/03/2007 |
Last Update Date | 19/01/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
061807327 | TAX IDENTIFICATION (01) | MI |