Healthcare Provider Details

I. General information

NPI: 1588734081
Provider Name (Legal Business Name): JONATHAN A AGBEBIYI MD.,CMHT.,MBA.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20755 GREENFIELD RD SUITE 100
SOUTHFIELD MI
48075
US

IV. Provider business mailing address

22200 W 11 MILE RD # 3455
SOUTHFIELD MI
48037-9991
US

V. Phone/Fax

Practice location:
  • Phone: 248-436-1959
  • Fax: 248-436-1978
Mailing address:
  • Phone: 248-436-1959
  • Fax: 248-436-1978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301041053
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number4301041053
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: