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General NPI Number Information
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NPI Number | 1093915910
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Entity Type | Organization
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Legal Business Name | MICHIGAN VASCULAR INSTITUTE PLLC
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Dates
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Enumeration Date | 07/19/2007
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Last Update Date | 02/23/2023
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Provider Practice Location Address
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Address Line | 538 N OLD WOODWARD AVE
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City | BIRMINGHAM
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State | MI
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Zip | 48009-5375
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Country | US
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Telephone | 248-594-3091
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Fax | 248-594-3068
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Provider Business Mailing Address
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Address Line | 538 N OLD WOODWARD AVE
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City | BIRMINGHAM
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State | MI
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Zip | 48009-5375
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Country | US
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Telephone | 248-594-3091
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Fax | 248-594-3068
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Authorized Official
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Title or Position | MEMBER
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Name | DR. GREGORY P. DERDERIAN
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Credential | D.O.
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Telephone | 248-594-3091
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 5101007182
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License Number State | MI
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