Healthcare Provider Details

I. General information

NPI: 1568664134
Provider Name (Legal Business Name): MICHAEL CLIFTON KAPSOKAVATHIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N OLD WOODWARD AVE SUITE 150
BIRMINGHAM MI
48009-1322
US

IV. Provider business mailing address

1268 SOUTHFIELD RD
BIRMINGHAM MI
48009-3082
US

V. Phone/Fax

Practice location:
  • Phone: 248-206-2100
  • Fax: 586-279-5864
Mailing address:
  • Phone: 248-206-2100
  • Fax: 586-279-5864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101016538
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number242354
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: