Healthcare Provider Details

I. General information

NPI: 1245337179
Provider Name (Legal Business Name): AUDREY J BRUELL DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37605 PEMBROKE AVE
LIVONIA MI
48152-1050
US

IV. Provider business mailing address

37605 PEMBROKE AVE
LIVONIA MI
48152-1050
US

V. Phone/Fax

Practice location:
  • Phone: 734-591-7931
  • Fax: 734-464-0335
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number4301062941
License Number StateMI

VIII. Authorized Official

Name: DAVID DURIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 517-505-0661