MEDICARE: MS. CHANNING COREANE ODAY PAC

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	363AS0400X	Surgical Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1063054	OTHER	MI	NCCPA CERTIFICATE NUMBER

General Provider Information

NPI Number	:	1194762161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHANNING COREANE ODAY PAC

Provider Business Mailing Address
First Line	:	5241 DOHERTY DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48323-3413
Country	:	US
Telephone Number	:	248-342-0074
Fax Number	:

Provider Business Practice Location Address
First Line	:	6777 W MAPLE RD
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-3013
Country	:	US
Telephone Number	:	248-325-1000
Fax Number	:

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

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	03/04/2026

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