Healthcare Provider Details

I. General information

NPI: 1295775757
Provider Name (Legal Business Name): STEPHEN D MIGDAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 JOHN R ST SUITE 917
DETROIT MI
48201-2017
US

IV. Provider business mailing address

1560 E MAPLE RD SUITE 400-CREDENTIALING
TROY MI
48083-1138
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4525
  • Fax: 313-745-0011
Mailing address:
  • Phone: 313-745-4525
  • Fax: 313-745-0011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301029339
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4301029339
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: