Healthcare Provider Details

I. General information

NPI: 1689129702
Provider Name (Legal Business Name): JEREMY REID HEFFERNAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2016
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22250 PROVIDENCE DR STE 301
SOUTHFIELD MI
48075-6211
US

IV. Provider business mailing address

22250 PROVIDENCE DR STE 301
SOUTHFIELD MI
48075-6211
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-3281
  • Fax: 248-849-8027
Mailing address:
  • Phone: 248-849-3281
  • Fax: 248-849-8027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberAP2742713-356
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301500220
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: