Provider Demographics
NPI:1548325186
Name:RUDY J VERVAEKE MD PLC
Entity type:Organization
Organization Name:RUDY J VERVAEKE MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:VERVAEKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-775-7400
Mailing Address - Street 1:24211 LITTLE MACK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1151
Mailing Address - Country:US
Mailing Address - Phone:586-775-7400
Mailing Address - Fax:586-775-0091
Practice Address - Street 1:24211 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1151
Practice Address - Country:US
Practice Address - Phone:586-775-7400
Practice Address - Fax:586-775-0091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044898207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI770666348OtherCOMMERCIAL
MIB47051Medicare UPIN