Healthcare Provider Details

I. General information

NPI: 1194918789
Provider Name (Legal Business Name): A AND G AESTHETICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 ORCHARD LAKE RD SUITE 120
WEST BLOOMFIELD MI
48322-3615
US

IV. Provider business mailing address

7125 ORCHARD LAKE RD STE 120
WEST BLOOMFIELD MI
48322-3627
US

V. Phone/Fax

Practice location:
  • Phone: 248-855-5355
  • Fax: 248-855-5455
Mailing address:
  • Phone: 866-607-2308
  • Fax: 248-855-5455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MATT KIRK
Title or Position: CHIEF REVENUE OFFICER
Credential:
Phone: 708-710-9931