Healthcare Provider Details

I. General information

NPI: 1720315807
Provider Name (Legal Business Name): JILLIAN DIANE DAVIS-BAUMANN D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILLIAN DIANE DAVIS D.O

II. Dates (important events)

Enumeration Date: 11/10/2009
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15855 NINTEEN MILED ROAD EMERGENCY DEPT
CLINTON TOWNSHIP MI
48038-3504
US

IV. Provider business mailing address

38935 ANN ARBOR RD CREDENTIALING DEPT
LIVONIA MI
48150-3397
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-2601
  • Fax: 586-263-2589
Mailing address:
  • Phone: 734-805-0488
  • Fax: 866-250-6385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101018413
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: