Healthcare Provider Details

I. General information

NPI: 1699805556
Provider Name (Legal Business Name): MICHIGAN COSMETIC & RECONSTRUCTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30603 SOUTHFIELD RD
SOUTHFIELD MI
48076-7729
US

IV. Provider business mailing address

30603 SOUTHFIELD RD
SOUTHFIELD MI
48076-7729
US

V. Phone/Fax

Practice location:
  • Phone: 248-540-1900
  • Fax: 248-767-8706
Mailing address:
  • Phone: 248-540-1900
  • Fax: 248-767-8706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301082433
License Number StateMI

VIII. Authorized Official

Name: MARIAM H AWADA
Title or Position: OWNER
Credential: MD
Phone: 248-540-1900