Healthcare Provider Details

I. General information

NPI: 1427211945
Provider Name (Legal Business Name): ELIZABETH A BLOMENBERG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 E 12 MILE RD
WARREN MI
48093-3472
US

IV. Provider business mailing address

1 FORD PL
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 586-576-4904
  • Fax:
Mailing address:
  • Phone: 313-874-4806
  • Fax: 313-876-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: