NPIMap

Individual provider Active NPI

Supak Sookkasikon, M.D.

  • Family Medicine Physician
  • Bloomfield Township, MI
National Provider Identifier
1649376922
Registry record updated Feb 28, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
4301083253 Issued in MI
Practice address
4050 W Maple Rd
Suite 101
Bloomfield Township, MI 48301-3148
Phone
(248) 885-8211
Fax
(248) 885-8357
NPI assigned
Sep 15, 2006
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Feb 28, 2014

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 4301083253 MI Primary

Addresses

Primary practice location

4050 W Maple Rd
Suite 101
Bloomfield Township, MI 48301-3148

Mailing address

4050 W Maple Rd
Suite 101
Bloomfield Township, MI 48301-3148
Phone (248) 885-8211

Other identifiers 1

IdentifierTypeStateIssuer
5315028426OtherMICONTROLLED SUBSTANCE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20070409000031 MI Practitioner - Family Practice 9537263132 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2003
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
A3 MedicalGroup PAC ID 7315183076, 2 clinicians

Practice addresses (Care Compare)

20490 Haggerty Rd
Northville, MI 48167-3955
Phone (248) 885-8821

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of tissue1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
A3 Primary Care CurrentSince May 30, 2024 Accepting new patients
A3 Medical Family Medicine CurrentSince Jun 1, 2012 Accepting new patients

Locations

4050 W Maple Rd
Ste 102
Bloomfield Hills, MI 48301
Phone (248) 885-8211

4050 W Maple Rd
Ste B
Bloomfield Hills, MI 48301
Phone (248) 885-8211

4050 W Maple Rd
Ste 101
Bloomfld Hls, MI 48301
Phone (248) 385-3412

20599 Mack Ave
Grosse Pointe Woods, MI 48236
Phone (248) 885-8211

20490 Haggerty Rd
Ste 101
Northville, MI 48167
Phone (248) 885-8211

20490 Haggerty Rd
Northville Township, MI 48167
Phone (248) 885-8821

2140 E 12 Mile Rd
Royal Oak, MI 48067
Phone (248) 885-8211

Interoperability endpoints

  • Direct secure messaging: supaksookkasikon@emcuramed.allscriptsdirect.net

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 15

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 15

NPI Registry JSON

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

{
    "created_epoch": "1158278400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1393545600000",
    "number": "1649376922",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4050 W MAPLE RD",
            "address_2": "SUITE 101",
            "city": "BLOOMFIELD TOWNSHIP",
            "state": "MI",
            "postal_code": "483013148",
            "telephone_number": "248-885-8211",
            "fax_number": "248-885-8357"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4050 W MAPLE RD",
            "address_2": "SUITE 101",
            "city": "BLOOMFIELD TOWNSHIP",
            "state": "MI",
            "postal_code": "483013148",
            "telephone_number": "248-885-8211",
            "fax_number": "248-885-8357"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SOOKKASIKON",
        "first_name": "SUPAK",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2006-09-15",
        "last_updated": "2014-02-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "4301083253",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CONTROLLED SUBSTANCE",
            "identifier": "5315028426",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Bloomfield Township, MI

Sources for this page

Verify at the official NPI Registry.