Provider Demographics
NPI:1538616008
Name:A. PETER EVANGELISTA, MD, PC
Entity type:Organization
Organization Name:A. PETER EVANGELISTA, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AUGUSTUS
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:
Authorized Official - Credentials:M
Authorized Official - Phone:248-626-0470
Mailing Address - Street 1:7071 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE 333
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3613
Mailing Address - Country:US
Mailing Address - Phone:248-626-0470
Mailing Address - Fax:248-626-0221
Practice Address - Street 1:10475 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-5704
Practice Address - Country:US
Practice Address - Phone:734-427-9440
Practice Address - Fax:734-427-1071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301108922207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301108922OtherLICENSE