Healthcare Provider Details

I. General information

NPI: 1760062814
Provider Name (Legal Business Name): MADELINE RUSZALA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELINE CONLEN

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22500 METRO PKWY STE 201
CLINTON TWP MI
48035-1943
US

IV. Provider business mailing address

3031 W GRAND BLVD STE 600
DETROIT MI
48202-3014
US

V. Phone/Fax

Practice location:
  • Phone: 586-493-3732
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101028033
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: