Healthcare Provider Details

I. General information

NPI: 1619339918
Provider Name (Legal Business Name): REZA KAHNAMOUEI MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43361 COMMONS DR
CLINTON TOWNSHIP MI
48038-1109
US

IV. Provider business mailing address

43361 COMMONS DR
CLINTON TOWNSHIP MI
48038-1109
US

V. Phone/Fax

Practice location:
  • Phone: 586-745-3006
  • Fax:
Mailing address:
  • Phone: 586-745-3006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. EMILIE MARIE PINEAU
Title or Position: OFFICE MANAGER
Credential:
Phone: 586-745-3006