Healthcare Provider Details

I. General information

NPI: 1801030218
Provider Name (Legal Business Name): MICHIGAN REPRODUCTIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41000 WOODWARD AVE SUITE 100 EAST
BLOOMFIELD HILLS MI
48304-5130
US

IV. Provider business mailing address

2830 MEADOWOOD LN
BLOOMFIELD MI
48302-1029
US

V. Phone/Fax

Practice location:
  • Phone: 248-593-6990
  • Fax: 248-593-5925
Mailing address:
  • Phone: 248-972-0877
  • Fax: 248-972-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberMM0056302
License Number StateMI

VIII. Authorized Official

Name: MARY JO MERSOL-BARG
Title or Position: MANAGER
Credential: MPA
Phone: 248-972-0877