Basic Information
| Provider Information | |||||||||
| NPI: | 1588907208 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BISSONETTE | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | HERBERT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 N HOWARD ST | ||||||||
| Address2: | APT. 406 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212013424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164902978 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2799 W GRAND BLVD | ||||||||
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| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006536568 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2013 | ||||||||
| LastUpdateDate: | 02/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4301501706 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 4301501706 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 4301501706 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No ID Information.