=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609086933
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OBGYN SPECIALTY GROUP, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2007
-----------------------------------------------------
Last Update Date | 10/16/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19830 JAMES COUZENS FWY
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48235-1938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-345-3144
-----------------------------------------------------
Fax | 313-345-3458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19830 JAMES COUZENS FWY
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48235-1938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-345-3144
-----------------------------------------------------
Fax | 313-345-3458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ALFRED C AUSTIN II
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 313-345-3144
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VH0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Obstetrics & Gynecology) Physician
-----------------------------------------------------
License Number | AA033474
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------