Healthcare Provider Details

I. General information

NPI: 1144110073
Provider Name (Legal Business Name): MI WELLNESS CLINIC PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2025
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27207 LAHSER RD STE 225
SOUTHFIELD MI
48034-2168
US

IV. Provider business mailing address

51 E 25TH ST FL 6
NEW YORK NY
10010-8207
US

V. Phone/Fax

Practice location:
  • Phone: 212-813-3632
  • Fax:
Mailing address:
  • Phone: 212-813-3632
  • Fax: 212-696-0162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL MARIE BRISSON
Title or Position: OWNER
Credential: MD
Phone: 646-380-7184