Healthcare Provider Details

I. General information

NPI: 1710654876
Provider Name (Legal Business Name): NOVUS MICHIGAN PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 S OAKLAND ST
SAINT JOHNS MI
48879-2253
US

IV. Provider business mailing address

PO BOX 12766
PENSACOLA FL
32591-2766
US

V. Phone/Fax

Practice location:
  • Phone: 989-224-6881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: CARRIE VAUGHAN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 404-419-0237