Healthcare Provider Details

I. General information

NPI: 1417905050
Provider Name (Legal Business Name): BRENDA WEINGARTEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202
US

IV. Provider business mailing address

2799 W GRAND BLVD
DETROIT MI
48202-2689
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-7425
  • Fax:
Mailing address:
  • Phone: 313-916-7425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number4301406120
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number4301406120
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301406120
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: