Healthcare Provider Details

I. General information

NPI: 1174603765
Provider Name (Legal Business Name): A MI SOH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18471 HAGGERTY RD
NORTHVILLE MI
48168-8513
US

IV. Provider business mailing address

3847 SPANISH OAKS DR
WEST BLOOMFIELD MI
48323-1867
US

V. Phone/Fax

Practice location:
  • Phone: 248-349-3000
  • Fax: 248-349-9552
Mailing address:
  • Phone: 248-682-3277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number043189
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: