Healthcare Provider Details

I. General information

NPI: 1245228790
Provider Name (Legal Business Name): MAURY RUBEN ELLENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 12/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28455 HAGGERTY RD SUITE 200
NOVI MI
48377-2982
US

IV. Provider business mailing address

6676 SOLUTIONS CTR
CHICAGO IL
60677-6006
US

V. Phone/Fax

Practice location:
  • Phone: 248-893-3200
  • Fax: 248-893-2950
Mailing address:
  • Phone: 248-893-3220
  • Fax: 248-893-2950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4301034191
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number4301034191
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number4301034191
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: