MEDICARE: DR. NISHAN CHOBANIAN JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VX0201X	Gynecologic Oncology Physician	4301110735	MI

General Provider Information

NPI Number	:	1104813633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NISHAN CHOBANIAN JR. MD

Provider Business Mailing Address
First Line	:	22301 FOSTER WINTER DR
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48075-3707
Country	:	US
Telephone Number	:	248-849-8140
Fax Number	:

Provider Business Practice Location Address
First Line	:	607 S NEW BALLAS RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8222
Country	:	US
Telephone Number	:	314-251-4260
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	01/03/2019

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