Provider Demographics
NPI:1316798267
Name:RATUSZNIK, MIRANDA MAE
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MAE
Last Name:RATUSZNIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22101 MOROSS RD
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2148
Mailing Address - Country:US
Mailing Address - Phone:313-343-3400
Mailing Address - Fax:313-343-4056
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-3400
Practice Address - Fax:313-343-4056
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351052409207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program