Healthcare Provider Details

I. General information

NPI: 1215999107
Provider Name (Legal Business Name): BERNARD ASONGANYI MBEBOH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 W GRAND BLVD STE 600
DETROIT MI
48202-3014
US

IV. Provider business mailing address

3031 W GRAND BLVD
DETROIT MI
48202-3046
US

V. Phone/Fax

Practice location:
  • Phone: 313-871-3751
  • Fax:
Mailing address:
  • Phone: 313-871-3751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC03163
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0099241
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: