Healthcare Provider Details

I. General information

NPI: 1558412551
Provider Name (Legal Business Name): BIRMINGHAM MAPLE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 W BIG BEAVER RD SUITE 520
TROY MI
48084-3407
US

IV. Provider business mailing address

2075 BIG BEAVER RD SUITE 520
TROY MI
48084
US

V. Phone/Fax

Practice location:
  • Phone: 248-646-6659
  • Fax: 248-642-8645
Mailing address:
  • Phone: 248-646-6659
  • Fax: 248-642-8645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. PERRI HOPE ROSEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 248-646-6659