Healthcare Provider Details

I. General information

NPI: 1093915910
Provider Name (Legal Business Name): MICHIGAN VASCULAR INSTITUTE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 N OLD WOODWARD AVE
BIRMINGHAM MI
48009-5375
US

IV. Provider business mailing address

538 N OLD WOODWARD AVE
BIRMINGHAM MI
48009-5375
US

V. Phone/Fax

Practice location:
  • Phone: 248-594-3091
  • Fax: 248-594-3068
Mailing address:
  • Phone: 248-594-3091
  • Fax: 248-594-3068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number5101007182
License Number StateMI

VIII. Authorized Official

Name: DR. GREGORY P. DERDERIAN
Title or Position: MEMBER
Credential: D.O.
Phone: 248-594-3091