Healthcare Provider Details

I. General information

NPI: 1316774110
Provider Name (Legal Business Name): PENINSULA PLASTIC AND RECONSTRUCTIVE SURGERY OF MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47601 GRAND RIVER AVE STE B233
NOVI MI
48374-1204
US

IV. Provider business mailing address

47601 GRAND RIVER AVE STE B233
NOVI MI
48374-1204
US

V. Phone/Fax

Practice location:
  • Phone: 248-465-5499
  • Fax:
Mailing address:
  • Phone: 248-465-5499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: RACHEL PERRY
Title or Position: CRED COORD
Credential:
Phone: 586-209-8307