Provider Demographics
NPI:1871949925
Name:VENDITTELLI, PHILIP STANLEY (DO)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:STANLEY
Last Name:VENDITTELLI
Suffix:
Gender:M
Credentials:DO
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 FL 2
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2148
Mailing Address - Country:US
Mailing Address - Phone:313-343-4612
Mailing Address - Fax:
Practice Address - Street 1:18303 E 10 MILE RD STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4989
Practice Address - Country:US
Practice Address - Phone:586-776-8877
Practice Address - Fax:586-776-3092
Is Sole Proprietor?:No
Enumeration Date:2016-05-08
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101022293207R00000X
MI51024546207RC0000X
MI5315204612207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101024546Medicaid