Healthcare Provider Details

I. General information

NPI: 1629575428
Provider Name (Legal Business Name): MADELINE VIRGINIA TERESA ROBINSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6777 W MAPLE RD
WEST BLOOMFIELD MI
48322-3013
US

IV. Provider business mailing address

16204 TRINITY ST
DETROIT MI
48219-4734
US

V. Phone/Fax

Practice location:
  • Phone: 248-325-1000
  • Fax:
Mailing address:
  • Phone: 248-790-3559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704177807
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: