Paul V Detrisac, MD

Primary specialty

Critical Care Medicine (Internal Medicine) PhysicianTaxonomy code 207RC0200X

License

PD043661 Issued in MI

Practice address

24 N St Joseph Ave
Niles, MI 49120

Phone

(269) 684-8356

NPI assigned

Sep 12, 2006

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in MI

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

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.

• Lakeland Medical Practices

  • Internal Medicine Physician
  • Saint Joseph, MI
  • NPI 1538397120
  Medicare reassignment NPD
• Lakeland Medical Practices

  • Internal Medicine Physician
  • Bridgman, MI
  • NPI 1568232247
  NPD
• Great Lakes Heart & Vascular Institute, P.C.

  • Cardiovascular Disease Physician
  • Saint Joseph, MI
  • NPI 1205911047
  NPD (past)
• Niles Professional Services, Inc

  • Internal Medicine Physician
  • Niles, MI
  • NPI 1568407930
  NPD (past)

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

{
    "created_epoch": "1158019200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1184025600000",
    "number": "1962506527",
    "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": "49120",
            "telephone_number": "269-684-8356"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "24 N ST JOSEPH AVE",
            "city": "NILES",
            "state": "MI",
            "postal_code": "49120",
            "telephone_number": "269-684-8356"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DETRISAC",
        "first_name": "PAUL",
        "middle_name": "V",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-12",
        "last_updated": "2007-07-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207RC0200X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Critical Care Medicine",
            "state": "MI",
            "license": "PD043661",
            "primary": true
        },
        {
            "code": "207RC0200X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Critical Care Medicine",
            "state": "IN",
            "license": "01032411A",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1508904",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Simona Davis, CPHT
• Jersie Dawson
• Filipe De Paula Santos
• Josie Maria Dejong, MA LPC SCL NCC
• Bobbie Denney
• Marcia Deuerling, R.D.
• Mary L Digangi, ED.D
• Dennis L Disch, M.D.
• Divine Grace Country Home LLC.
• Dockerty Health Care Services Inc.

• Critical Care Medicine (Internal Medicine) Physician in Niles, MI
• Providers in Niles, MI by specialty
• Critical Care Medicine (Internal Medicine) Physician in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 10, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.