Healthcare Provider Details

I. General information

NPI: 1356380935
Provider Name (Legal Business Name): MICHAEL SCOTT BROAD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 SOUTH BLVD E SUITE 310
ROCHESTER HILLS MI
48307-5605
US

IV. Provider business mailing address

1635 FAIRHOLME RD
GROSSE POINTE WOODS MI
48236-2368
US

V. Phone/Fax

Practice location:
  • Phone: 248-215-8095
  • Fax: 248-289-1086
Mailing address:
  • Phone: 313-882-5473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601003846
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: