Provider Demographics
NPI:1831192483
Name:PURTILL, MARY ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:MARY ANNE
Middle Name:
Last Name:PURTILL
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:PO BOX 67000
Mailing Address - Street 2:DEPARTMENT 272801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-817-7605
Mailing Address - Fax:517-817-7606
Practice Address - Street 1:1100 E MICHIGAN AVE
Practice Address - Street 2:STE 201
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1847
Practice Address - Country:US
Practice Address - Phone:517-817-7605
Practice Address - Fax:517-817-7606
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010753972086S0127X
CAG076836208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZP4310ZOtherMEDICARE ID - STANFORD SURGERY DEPT
MIM95720072Medicare PIN
CAZZZP4310ZOtherMEDICARE ID - STANFORD SURGERY DEPT