Healthcare Provider Details

I. General information

NPI: 1902334584
Provider Name (Legal Business Name): MICHAEL GUMBO RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2017
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 NORTH AVE
MOUNT CLEMENS MI
48043-9717
US

IV. Provider business mailing address

44695 BAYVIEW AVE APT 4304
CLINTON TOWNSHIP MI
48038-1592
US

V. Phone/Fax

Practice location:
  • Phone: 269-240-7881
  • Fax:
Mailing address:
  • Phone: 269-240-7881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704273339
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: