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General NPI Number Information
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NPI Number | 1720669880
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Entity Type | Organization
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Legal Business Name | ENDOMETRIOSIS TREATMENT CENTER OF AMERICA - MICHIGAN PLLC
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Dates
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Enumeration Date | 04/19/2021
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Last Update Date | 03/06/2025
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Provider Practice Location Address
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Address Line | 1430 S LAPEER RD
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City | LAKE ORION
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State | MI
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Zip | 48360-1437
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Country | US
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Telephone | 248-693-1630
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Fax | 248-731-2156
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Provider Business Mailing Address
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Address Line | 1430 S LAPEER RD
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City | LAKE ORION
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State | MI
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Zip | 48360-1437
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Country | US
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Telephone | 248-693-1630
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Fax | 248-731-2156
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Authorized Official
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Title or Position | CEO
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Name | JONATHAN ZAIDAN
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Credential | MD
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Telephone | 248-693-1630
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207VF0040X
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Taxonomy Name | Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207VX0201X
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Taxonomy Name | Gynecologic Oncology Physician
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License Number |
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License Number State |
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