Healthcare Provider Details

I. General information

NPI: 1891796371
Provider Name (Legal Business Name): CRAIG J EVERINGHAM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12100 S HURON RIVER DR
ROMULUS MI
48174-1119
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 734-941-1070
  • Fax: 734-941-1763
Mailing address:
  • Phone: 947-522-1863
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number381898373
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: