Healthcare Provider Details

I. General information

NPI: 1265756480
Provider Name (Legal Business Name): GROSSE POINTE COMPREHENSIVE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2010
Last Update Date: 12/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18348 MACK AVE
GROSSE POINTE FARMS MI
48236-3219
US

IV. Provider business mailing address

9600 DEXTER AVE
DETROIT MI
48206-1816
US

V. Phone/Fax

Practice location:
  • Phone: 313-881-7010
  • Fax:
Mailing address:
  • Phone: 313-881-7010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301045243
License Number StateMI

VIII. Authorized Official

Name: CARL FOWLER
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 313-881-7010