Healthcare Provider Details

I. General information

NPI: 1962220053
Provider Name (Legal Business Name): MICHIGAN MOBILE MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2024
Last Update Date: 09/28/2024
Certification Date: 09/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43700 WOODWARD AVE STE 207
BLOOMFIELD HILLS MI
48302-5061
US

IV. Provider business mailing address

43700 WOODWARD AVE STE 207
BLOOMFIELD HILLS MI
48302-5061
US

V. Phone/Fax

Practice location:
  • Phone: 248-481-2100
  • Fax: 248-359-8750
Mailing address:
  • Phone: 248-481-2100
  • Fax: 248-359-8750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: DIEGO A HERNANDEZ
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 248-481-2100