Healthcare Provider Details

I. General information

NPI: 1306027842
Provider Name (Legal Business Name): AARON KOBERNICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48801 ROMEO PLANK RD STE 103A
MACOMB MI
48044-2165
US

IV. Provider business mailing address

1500 W BIG BEAVER RD STE 107
TROY MI
48084-3522
US

V. Phone/Fax

Practice location:
  • Phone: 248-689-1000
  • Fax: 248-689-5711
Mailing address:
  • Phone: 248-689-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number9717129-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD.201983
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.201983
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number9717129-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: