Healthcare Provider Details

I. General information

NPI: 1629297270
Provider Name (Legal Business Name): MICHAEL DENNIS MAHONEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29751 LITTLE MACK AVE SUITE B
ROSEVILLE MI
48066-6503
US

IV. Provider business mailing address

29751 LITTLE MACK AVE SUITE B
ROSEVILLE MI
48066-6503
US

V. Phone/Fax

Practice location:
  • Phone: 586-415-6200
  • Fax: 586-415-6217
Mailing address:
  • Phone: 586-415-6200
  • Fax: 586-415-6217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number4301082053
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301082053
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: