Healthcare Provider Details

I. General information

NPI: 1962995480
Provider Name (Legal Business Name): JOHN KAORU GEDDES MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2018
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18325 E 10 MILE RD STE 300
ROSEVILLE MI
48066-4990
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 586-447-4000
  • Fax: 586-447-4008
Mailing address:
  • Phone: 947-522-1952
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351040074
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: