Healthcare Provider Details

I. General information

NPI: 1972890085
Provider Name (Legal Business Name): DIANA MARIE FLIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2011
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3305 SPRING ARBOR RD STE 200
JACKSON MI
49203-3995
US

IV. Provider business mailing address

6830 PRICE LAKE RD N
JACKSON MI
49201-8013
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-2107
  • Fax:
Mailing address:
  • Phone: 313-300-9630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301098769
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: