Provider Demographics
NPI:1386699791
Name:FITZPATRICK-SHERMAN, VIVICA J (MD)
Entity type:Individual
Prefix:
First Name:VIVICA
Middle Name:J
Last Name:FITZPATRICK-SHERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2864 ASHMUN STREET
Mailing Address - Street 2:
Mailing Address - City:SAULT STE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783
Mailing Address - Country:US
Mailing Address - Phone:906-632-5200
Mailing Address - Fax:906-632-5276
Practice Address - Street 1:2864 ASHMUN STREET
Practice Address - Street 2:SAULT TRIBAL HEALTH CENTER
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783
Practice Address - Country:US
Practice Address - Phone:906-632-5200
Practice Address - Fax:906-632-5276
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053961208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080A760010OtherBCBS
MI1969581Medicaid
MI4410400Medicaid
0A76001002Medicare ID - Type Unspecified
MI080A760010OtherBCBS