Healthcare Provider Details

I. General information

NPI: 1205002342
Provider Name (Legal Business Name): MODERN OBSTETRICS & GYNECOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5793 W MAPLE RD STE 147
WEST BLOOMFIELD MI
48322-4478
US

IV. Provider business mailing address

5793 W MAPLE RD STE 147
WEST BLOOMFIELD MI
48322-4478
US

V. Phone/Fax

Practice location:
  • Phone: 248-862-7221
  • Fax: 248-970-2941
Mailing address:
  • Phone: 248-862-7221
  • Fax: 248-970-2941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAY E FISHER
Title or Position: PHYSICIAN/ PRESIDENT
Credential: MD
Phone: 248-862-7221