Healthcare Provider Details

I. General information

NPI: 1295817799
Provider Name (Legal Business Name): MICHIGAN INSTITUTE OF UROLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 TOWN CENTER DRIVE SUITE 101
TROY MI
48084-1773
US

IV. Provider business mailing address

20952 12 MILE ROAD SUITE 200
ST. CLAIR SHORES MI
48081-3203
US

V. Phone/Fax

Practice location:
  • Phone: 248-740-0670
  • Fax: 248-740-0668
Mailing address:
  • Phone: 586-771-4820
  • Fax: 586-771-6620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JASON HAFRON
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 586-771-4820