Healthcare Provider Details

I. General information

NPI: 1104866730
Provider Name (Legal Business Name): JOHN G BLOODWORTH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 METROPOLITAN PKWY SUITE 101
STERLING HTS MI
48310-7503
US

IV. Provider business mailing address

4105 METROPOLITAN PKWY SUITE 101
STERLING HTS MI
48310-7503
US

V. Phone/Fax

Practice location:
  • Phone: 586-939-1003
  • Fax: 586-939-3862
Mailing address:
  • Phone: 586-939-1003
  • Fax: 586-939-3862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301007508
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: