Healthcare Provider Details

I. General information

NPI: 1912951807
Provider Name (Legal Business Name): MAURA P O'CONNELL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 02/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19020 FORT ST
RIVERVIEW MI
48193-6701
US

IV. Provider business mailing address

19020 FORT ST
RIVERVIEW MI
48193-6701
US

V. Phone/Fax

Practice location:
  • Phone: 734-362-5100
  • Fax: 734-362-5147
Mailing address:
  • Phone: 734-362-5100
  • Fax: 734-362-5147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101015548
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: