=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679709976
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLOOMFIELD OBGYN SPECIALISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2009
-----------------------------------------------------
Last Update Date | 07/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1750 S TELEGRAPH RD SUITE 108
-----------------------------------------------------
City | BLOOMFIELD HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48302-0166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-858-2202
-----------------------------------------------------
Fax | 248-338-6185
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1750 S TELEGRAPH RD SUITE 108
-----------------------------------------------------
City | BLOOMFIELD HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48302-0166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-858-2202
-----------------------------------------------------
Fax | 248-338-6185
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JENNIFER L HOLAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 248-858-2202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 4301062815
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------