Healthcare Provider Details

I. General information

NPI: 1992704167
Provider Name (Legal Business Name): ROGER JONATHAN ONG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 W 9 MILE RD # 3
SOUTHFIELD MI
48075-4818
US

IV. Provider business mailing address

16001 W 9 MILE RD # 3
SOUTHFIELD MI
48075-4818
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-2600
  • Fax: 248-849-2610
Mailing address:
  • Phone: 248-849-2600
  • Fax: 248-849-2610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601003732
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: