Healthcare Provider Details

I. General information

NPI: 1720329220
Provider Name (Legal Business Name): DHOM ANESTHESIA ADMINISTRATIVE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2013
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 W HURON ST
PONTIAC MI
48341-1601
US

IV. Provider business mailing address

1102 WOODSIDE DR
FLINT MI
48503-5341
US

V. Phone/Fax

Practice location:
  • Phone: 248-857-7310
  • Fax:
Mailing address:
  • Phone: 810-869-0397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301061430
License Number StateMI

VIII. Authorized Official

Name: ANGELA JOSEPH
Title or Position: OWNER
Credential: MD
Phone: 810-869-0397