Healthcare Provider Details

I. General information

NPI: 1902072952
Provider Name (Legal Business Name): MICHIGAN COSMETIC & RECONSTRUCTIVE SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29110 INKSTER RD STE 250
SOUTHFIELD MI
48034-1098
US

IV. Provider business mailing address

PO BOX 673053
DETROIT MI
48267-3053
US

V. Phone/Fax

Practice location:
  • Phone: 248-948-5500
  • Fax: 248-948-8085
Mailing address:
  • Phone: 248-948-5500
  • Fax: 248-948-8085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIAM AWADA
Title or Position: PRESIDENT
Credential: MD
Phone: 248-948-5500