NPIMap

Organization Active NPI

Paul V Detrisac MD PC

  • Internal Medicine Physician
  • Niles, MI
National Provider Identifier
1629277439
Registry record updated Jul 12, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
PAUL V DETRISAC MD PC
Practice address
24 N Saint Joseph Ave
Niles, MI 49120-2263
Phone
(269) 684-8356
NPI assigned
Jul 12, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 12, 2007

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Paul V DetrisacNPI 1962506527
Title
President
Phone
(269) 684-8356

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207R00000X Primary

Addresses

Primary practice location

24 N Saint Joseph Ave
Niles, MI 49120-2263

Mailing address

PO Box 998
Niles, MI 49120-0998

National Provider Directory

National Provider Directory

Locations

24 N Saint Joseph Ave
Niles, MI 49120
Phone (269) 683-1120

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1184198400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1184198400000",
    "number": "1629277439",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 998",
            "city": "NILES",
            "state": "MI",
            "postal_code": "491200998"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "24 N SAINT JOSEPH AVE",
            "city": "NILES",
            "state": "MI",
            "postal_code": "491202263",
            "telephone_number": "269-684-8356"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PAUL V DETRISAC MD PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-07-12",
        "last_updated": "2007-07-12",
        "status": "A",
        "authorized_official_last_name": "DETRISAC",
        "authorized_official_first_name": "PAUL",
        "authorized_official_middle_name": "V",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "269-684-8356",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Niles, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 12, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.