Healthcare Provider Details

I. General information

NPI: 1265499206
Provider Name (Legal Business Name): ANTHONY STALLION M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 W 13 MILE RD STE 307
ROYAL OAK MI
48073-6770
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 248-551-2400
  • Fax:
Mailing address:
  • Phone: 947-522-4352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number35060022S
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number2013-01542
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number4301063442
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: