=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508166513
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WAYNE TREVOR, J NORTH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2010
-----------------------------------------------------
Last Update Date | 07/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2799 W GRAND BLVD 12TH FLOOR K BUILDING
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-904-8743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2799 W GRAND BLVD 12TH FLOOR K BUILDING -
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-904-8743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0114X
-----------------------------------------------------
Taxonomy Name | Adult Reconstructive Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 35.125720
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XS0114X
-----------------------------------------------------
Taxonomy Name | Adult Reconstructive Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 4301096246
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 4301096246
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------