Healthcare Provider Details

I. General information

NPI: 1063159291
Provider Name (Legal Business Name): SAMANTHA KOHLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SAMANTHA PETERS PA

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18101 OAKWOOD BLVD
DEARBORN MI
48124-4089
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 313-593-7000
  • Fax: 734-446-9750
Mailing address:
  • Phone: 947-522-1952
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011126
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: