Healthcare Provider Details

I. General information

NPI: 1669809612
Provider Name (Legal Business Name): MICHIGAN ORTHOPAEDIC SPINE SURGEONS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2013
Last Update Date: 10/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29624 WOODWARD AVE
ROYAL OAK MI
48073-0905
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 248-215-8080
  • Fax: 248-289-1085
Mailing address:
  • Phone: 248-215-8095
  • Fax: 248-289-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number4301051364
License Number StateMI

VIII. Authorized Official

Name: RICHARD W EASTON
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 248-215-8095