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General NPI Number Information
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NPI Number | 1801030218
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Entity Type | Organization
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Legal Business Name | MICHIGAN REPRODUCTIVE MEDICINE
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Dates
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Enumeration Date | 04/29/2009
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Last Update Date | 10/08/2013
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Provider Practice Location Address
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Address Line | 41000 WOODWARD AVE SUITE 100 EAST
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City | BLOOMFIELD HILLS
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State | MI
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Zip | 48304-5130
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Country | US
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Telephone | 248-593-6990
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Fax | 248-593-5925
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Provider Business Mailing Address
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Address Line | 2830 MEADOWOOD LN
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City | BLOOMFIELD
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State | MI
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Zip | 48302-1029
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Country | US
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Telephone | 248-972-0877
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Fax | 248-972-0880
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Authorized Official
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Title or Position | MANAGER
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Name | MARY JO MERSOL-BARG
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Credential | MPA
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Telephone | 248-972-0877
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VE0102X
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Taxonomy Name | Reproductive Endocrinology Physician
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License Number | MM0056302
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License Number State | MI
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