Healthcare Provider Details

I. General information

NPI: 1558497206
Provider Name (Legal Business Name): MICHAEL C. COELLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16815 E JEFFERSON AVE STE 240
GROSSE POINTE MI
48230-1923
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 313-473-4690
  • Fax:
Mailing address:
  • Phone: 947-522-1865
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberL-228805
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301095394
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: