Provider Demographics
NPI:1053409268
Name:BRUCE A. CASSIDY, D.O., PC
Entity type:Organization
Organization Name:BRUCE A. CASSIDY, D.O., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-308-2604
Mailing Address - Street 1:PO BOX 673102
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-3102
Mailing Address - Country:US
Mailing Address - Phone:248-308-2604
Mailing Address - Fax:248-308-2608
Practice Address - Street 1:28080 GRAND RIVER AVE STE 208N
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5966
Practice Address - Country:US
Practice Address - Phone:248-308-2604
Practice Address - Fax:248-308-2608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBC013348207R00000X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1156307745OtherBCBS
MI114334390Medicaid
MI1770568198OtherINDIVIDUAL NPI
MIBC013348OtherMI STATE LICENSE
MIBC013348OtherMI STATE LICENSE
MIH27703Medicare UPIN