MEDICARE: HEALTHSPAN PLLC

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	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1245086750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHSPAN PLLC

Provider Business Mailing Address
First Line	:	18450 MACK AVE STE 101
Second Line	:
City	:	GROSSE POINTE FARMS
State	:	MI
Zip	:	48236-3222
Country	:	US
Telephone Number	:	313-583-4333
Fax Number	:	313-432-8135

Provider Business Practice Location Address
First Line	:	18450 MACK AVE STE 101
Second Line	:
City	:	GROSSE POINTE FARMS
State	:	MI
Zip	:	48236-3222
Country	:	US
Telephone Number	:	313-583-4333
Fax Number	:	313-432-8135

Authorized Official
Title or Position	:	CARDIOLOGIST/OWNER
Name	:	GINETTE GOMEZ
Credential	:	DO
Telephone Number	:	313-583-4333

Provider Enumeration Date	:	04/25/2024
Last Update Date	:	04/25/2024

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