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General NPI Number Information
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NPI Number | 1619717881
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Entity Type | Individual
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Provider Name | MUTIU O BALOGUN NP
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Gender | Male
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Dates
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Enumeration Date | 05/27/2024
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Last Update Date | 05/27/2024
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Provider Practice Location Address
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Address Line | 1525 UNIVERSITY DR
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City | AUBURN HILLS
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State | MI
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Zip | 48326-2673
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Country | US
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Telephone | 313-434-2315
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Fax |
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Provider Business Mailing Address
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Address Line | 700 CALVERT ST
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City | DETROIT
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State | MI
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Zip | 48202-1200
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Country | US
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Telephone | 313-434-2315
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 4704334959
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License Number State | MI
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