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General NPI Number Information
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NPI Number | 1932459468
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Entity Type | Organization
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Legal Business Name | PHYSIQUE MEDICAL WELLNES CLINIC PLLC
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Dates
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Enumeration Date | 09/12/2012
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Last Update Date | 09/12/2012
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Provider Practice Location Address
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Address Line | 23815 NORTHWESTERN HWY
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City | SOUTHFIELD
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State | MI
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Zip | 48075-7738
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Country | US
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Telephone | 248-208-9079
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Fax | 248-208-9079
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Provider Business Mailing Address
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Address Line | 23815 NORTHWESTERN HWY
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City | SOUTHFIELD
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State | MI
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Zip | 48075-7738
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Country | US
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Telephone | 248-208-9079
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Fax | 248-208-9079
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Authorized Official
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Title or Position | OWNER
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Name | MS. ANGELA L ROMAN
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Credential | MSN, FNP-BC
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Telephone | 248-908-9079
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2083P0901X
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Taxonomy Name | Public Health & General Preventive Medicine Physician
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License Number |
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License Number State |
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