Healthcare Provider Details

I. General information

NPI: 1730190679
Provider Name (Legal Business Name): MARY GORDON CORNELIUS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 S TELEGRAPH RD STE 100
BLOOMFIELD HILLS MI
48302-0202
US

IV. Provider business mailing address

2520 S TELEGRAPH RD SUITE 200
BLOOMFIELD HILLS MI
48302-0285
US

V. Phone/Fax

Practice location:
  • Phone: 248-335-9207
  • Fax: 248-335-2394
Mailing address:
  • Phone: 248-335-9207
  • Fax: 248-335-2394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number5101013601
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: