Healthcare Provider Details

I. General information

NPI: 1770932782
Provider Name (Legal Business Name): IAN MOGG R. N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 MCAULEY DR
YPSILANTI MI
48197-1051
US

IV. Provider business mailing address

9440 NEWTON CT
COMMERCE TOWNSHIP MI
48390-1333
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-3456
  • Fax:
Mailing address:
  • Phone: 248-767-2616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number4704263900
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: