Healthcare Provider Details

I. General information

NPI: 1891359279
Provider Name (Legal Business Name): MATTHEW WILLIAM OGREN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6071 W OUTER DR
DETROIT MI
48235-2624
US

IV. Provider business mailing address

1511 1ST ST APT 509
DETROIT MI
48226-1355
US

V. Phone/Fax

Practice location:
  • Phone: 313-966-3329
  • Fax:
Mailing address:
  • Phone: 248-521-0030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDR.0068070
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: