Healthcare Provider Details

I. General information

NPI: 1720079437
Provider Name (Legal Business Name): JAMES M KOHLENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26505 JOHN R RD
MADISON HEIGHTS MI
48071-3611
US

IV. Provider business mailing address

26505 JOHN R RD
MADISON HEIGHTS MI
48071-3611
US

V. Phone/Fax

Practice location:
  • Phone: 248-547-3100
  • Fax: 248-547-4733
Mailing address:
  • Phone: 248-547-3100
  • Fax: 248-547-4733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number4301038982
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301038982
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: