Healthcare Provider Details

I. General information

NPI: 1134894934
Provider Name (Legal Business Name): MORGAN BROOKE CAUDILL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MORGAN BROOKE FOSTER

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

2799 W GRAND BLVD DEPT CARDIAC
DETROIT MI
48202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 800-653-6568
  • Fax: 313-876-1307
Mailing address:
  • Phone: 800-653-6568
  • Fax: 313-876-1307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010745
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: