Healthcare Provider Details

I. General information

NPI: 1518936590
Provider Name (Legal Business Name): ADVANCED UROGYNECOLOGY OF MICHIGAN, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22731 NEWMAN ST STE 200
DEARBORN MI
48124-2023
US

IV. Provider business mailing address

22731 NEWMAN STREET SUITE 200
DEARBORN MI
48124
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-0200
  • Fax: 313-982-0500
Mailing address:
  • Phone: 313-982-0200
  • Fax: 313-982-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DOLLANDRA CARBIN
Title or Position: BILLING AND CREDENTIALING
Credential:
Phone: 313-982-0228