Healthcare Provider Details

I. General information

NPI: 1144386053
Provider Name (Legal Business Name): PROFESSIONAL OBGYN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20276 MIDDLEBELT RD SUITE 2
LIVONIA MI
48152-2054
US

IV. Provider business mailing address

20276 MIDDLEBELT RD STE 2
LIVONIA MI
48152-2054
US

V. Phone/Fax

Practice location:
  • Phone: 248-476-4900
  • Fax: 248-476-5435
Mailing address:
  • Phone: 248-476-4900
  • Fax: 248-476-5435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: DR. ROGER KUSHNER
Title or Position: PRESIDENT
Credential: DO
Phone: 248-476-4900