Healthcare Provider Details

I. General information

NPI: 1962637892
Provider Name (Legal Business Name): KENNETH EICHENBAUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44201 DEQUINDRE RD
TROY MI
48085-1117
US

IV. Provider business mailing address

PO BOX 551420
FORT LAUDERDALE FL
33355-1420
US

V. Phone/Fax

Practice location:
  • Phone: 248-964-5000
  • Fax:
Mailing address:
  • Phone: 800-243-3839
  • Fax: 844-414-8291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA124518
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301108718
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: