Healthcare Provider Details

I. General information

NPI: 1609086933
Provider Name (Legal Business Name): OBGYN SPECIALTY GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19830 JAMES COUZENS FWY
DETROIT MI
48235-1938
US

IV. Provider business mailing address

19830 JAMES COUZENS FWY
DETROIT MI
48235-1938
US

V. Phone/Fax

Practice location:
  • Phone: 313-345-3144
  • Fax: 313-345-3458
Mailing address:
  • Phone: 313-345-3144
  • Fax: 313-345-3458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VH0002X
TaxonomyHospice and Palliative Medicine (Obstetrics & Gynecology) Physician
License NumberAA033474
License Number StateMI

VIII. Authorized Official

Name: DR. ALFRED C AUSTIN II
Title or Position: OWNER
Credential: MD
Phone: 313-345-3144