Healthcare Provider Details

I. General information

NPI: 1962694661
Provider Name (Legal Business Name): DR. J. THWAINEY MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7106 PARK AVE
ALLEN PARK MI
48101-2038
US

IV. Provider business mailing address

7106 PARK AVE
ALLEN PARK MI
48101-2038
US

V. Phone/Fax

Practice location:
  • Phone: 313-383-8310
  • Fax: 313-383-2756
Mailing address:
  • Phone: 313-383-8310
  • Fax: 313-383-2756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301047446
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301047446
License Number StateMI

VIII. Authorized Official

Name: DR. JALAL THWAINEY
Title or Position: OWNER
Credential: MD
Phone: 313-383-8310