Basic Information
| Provider Information | |||||||||
| NPI: | 1588624068 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUSK | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 342 BALDWIN RD | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480091360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135980878 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6071 W OUTER DR | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482352624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139663300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 04/20/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 5101010317 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 114604593 | 05 | MI | MEDICAID | 113402922 | 05 | MI | MEDICAID | WL010317 | 01 | MI | BC/BS OF MI | OTHER |