Healthcare Provider Details

I. General information

NPI: 1043198732
Provider Name (Legal Business Name): MATTHEW NORMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44201 DEQUINDRE RD
TROY MI
48085
US

IV. Provider business mailing address

1118 FAIRWAYS BLVD
TROY MI
48085
US

V. Phone/Fax

Practice location:
  • Phone: 248-964-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704360087
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: