Basic Information
| Provider Information | |||||||||
| NPI: | 1619231842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAURIE | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STANCZYK | ||||||||
| OtherFirstName: | ANNA | ||||||||
| OtherMiddleName: | ROSE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1801 BRIARWOOD CIRCLE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481083347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349987390 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2012 | ||||||||
| LastUpdateDate: | 05/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301101273 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | 4301101273 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.