Healthcare Provider Details

I. General information

NPI: 1730116682
Provider Name (Legal Business Name): EILEEN MARIE DONOVAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18501 ROTUNDA DR STE 200
DEARBORN MI
48124-3891
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 313-996-1960
  • Fax: 313-996-1965
Mailing address:
  • Phone: 947-522-1863
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number4304065585
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: