Healthcare Provider Details

I. General information

NPI: 1831308857
Provider Name (Legal Business Name): IMANI K. THORNTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IMANI K. HOLMES

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 03/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-8234
  • Fax:
Mailing address:
  • Phone: 313-916-8445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301085617
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: