Healthcare Provider Details

I. General information

NPI: 1124274329
Provider Name (Legal Business Name): GENESYS REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 TREE TOP CIR APT 206
AUBURN HILLS MI
48326-1185
US

IV. Provider business mailing address

235 TREE TOP CIR APT 206
AUBURN HILLS MI
48326-1185
US

V. Phone/Fax

Practice location:
  • Phone: 515-779-1412
  • Fax:
Mailing address:
  • Phone: 515-779-1412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number5315030686
License Number StateMI

VIII. Authorized Official

Name: DR. DEBORAH GESS RISTVEDT
Title or Position: OPHTHALMOLOGY RESIDENT
Credential: DO
Phone: 515-779-1412