Healthcare Provider Details

I. General information

NPI: 1164469680
Provider Name (Legal Business Name): BERNARD GONIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SINAI GRACE HOSPITAL-ATENATAL DIAGNOSTIC UNIT 6071 W OUTER DR
DETROIT MI
48235
US

IV. Provider business mailing address

1560 E MAPLE RD SUITE 400-CREDENTIALING
TROY MI
48083-1189
US

V. Phone/Fax

Practice location:
  • Phone: 313-966-1880
  • Fax: 313-966-1816
Mailing address:
  • Phone: 313-966-1880
  • Fax: 313-966-1816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number4301040951
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: