Healthcare Provider Details

I. General information

NPI: 1629730353
Provider Name (Legal Business Name): DYNAMIC MANAGEMENT GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2021
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33464 SCHOENHERR RD STE 160
STERLING HEIGHTS MI
48312-6392
US

IV. Provider business mailing address

33464 SCHOENHERR RD STE 160
STERLING HEIGHTS MI
48312-6392
US

V. Phone/Fax

Practice location:
  • Phone: 586-585-6500
  • Fax: 586-585-6852
Mailing address:
  • Phone: 586-585-6500
  • Fax: 586-585-6852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHERINE L NOVAK
Title or Position: OWNER
Credential: PA-C
Phone: 586-585-6500