Healthcare Provider Details

I. General information

NPI: 1023080694
Provider Name (Legal Business Name): PROVIDENCE CARDIOLOGY SERVICES I
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 W 9 MILE RD
SOUTHFIELD MI
48075-4818
US

IV. Provider business mailing address

22250 PROVIDENCE DR SUITE 705
SOUTHFIELD MI
48075-4825
US

V. Phone/Fax

Practice location:
  • Phone: 248-552-9858
  • Fax: 248-552-9510
Mailing address:
  • Phone: 248-552-9858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: ISSAC GRINBERG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 248-552-9858