Healthcare Provider Details

I. General information

NPI: 1093749095
Provider Name (Legal Business Name): MICHIGAN COLON & RECTAL SURGEONS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 05/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18161 W 13 MILE RD SUITE A1
SOUTHFIELD MI
48076-1113
US

IV. Provider business mailing address

18161 W 13 MILE RD. SUITE B-1
SOUTHFIELD MI
48076
US

V. Phone/Fax

Practice location:
  • Phone: 248-644-3711
  • Fax: 248-644-2864
Mailing address:
  • Phone: 248-644-3711
  • Fax: 248-644-2864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: GINGER G KLEINERT
Title or Position: OFFICE MANAGER
Credential:
Phone: 248-644-3711