Healthcare Provider Details

I. General information

NPI: 1508482514
Provider Name (Legal Business Name): MADELYN ROSE AITTAMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22101 MOROSS RD
DETROIT MI
48236-2148
US

IV. Provider business mailing address

22101 MOROSS RD
DETROIT MI
48236-2148
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-3400
  • Fax: 313-343-4056
Mailing address:
  • Phone: 313-343-3400
  • Fax: 313-343-4056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4351049162
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: