=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821813189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRM GYNECOLOGY OF MICHIGAN PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2024
-----------------------------------------------------
Last Update Date | 11/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1777 AXTELL DR STE 105
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48084-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-282-2202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2090 PALM BEACH LAKES BLVD STE 700
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33409-6508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-422-4206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF RCM
-----------------------------------------------------
Name | JANE LAGNESE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-422-4206
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------