Healthcare Provider Details

I. General information

NPI: 1154082428
Provider Name (Legal Business Name): JOSEPH ADVANCED FACIAL PLASTIC SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 07/07/2024
Certification Date: 07/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3940 JOHN R RD
TROY MI
48083-5688
US

IV. Provider business mailing address

3435 LIVERNOIS RD
TROY MI
48083-5063
US

V. Phone/Fax

Practice location:
  • Phone: 947-217-3223
  • Fax:
Mailing address:
  • Phone: 947-217-3223
  • Fax: 248-817-3994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHANNON S. JOSEPH
Title or Position: MEMBER
Credential: MD
Phone: 947-217-3223