Healthcare Provider Details

I. General information

NPI: 1477917466
Provider Name (Legal Business Name): BERTA REZIK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

300 RIVERFRONT DR UNIT 10C
DETROIT MI
48226-4572
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301119217
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: