=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891959458
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER ANN CRONOVICH D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2008
-----------------------------------------------------
Last Update Date | 10/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15855 19 MILE RD EMERGENCY MEDICINE DEPARTMENT
-----------------------------------------------------
City | CLINTON TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48038-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-263-2601
-----------------------------------------------------
Fax | 586-263-2589
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38925 ANN ARBOR ROAD CREDENTIALING/PAYER CONTRACTING SERVICES
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48150-3397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-632-0175
-----------------------------------------------------
Fax | 734-632-0182
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 5101017322
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------