Healthcare Provider Details

I. General information

NPI: 1245203454
Provider Name (Legal Business Name): MICHAEL ROBERT ISRAEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18181 OAKWOOD BLVD STE 212
DEARBORN MI
48124-5031
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 313-438-7397
  • Fax: 313-438-7398
Mailing address:
  • Phone: 947-522-1863
  • Fax: 47-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301044171
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301044171
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: