Healthcare Provider Details

I. General information

NPI: 1477602480
Provider Name (Legal Business Name): PROFESSIONAL OBGYN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 N POND DR SUITE 2
WALLED LAKE MI
48390-3080
US

IV. Provider business mailing address

20276 MIDDLEBELT RD SUITE 2
LIVONIA MI
48152-2054
US

V. Phone/Fax

Practice location:
  • Phone: 248-624-3366
  • Fax: 248-624-0127
Mailing address:
  • Phone: 248-476-4900
  • Fax: 248-476-5435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROGER KUSHNER
Title or Position: PRESIDENT
Credential: D.O.
Phone: 248-476-4900