MEDICARE: COLLEEN RENEE MAHESWARAN

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	176B00000X	Midwife	7602000007	MI

General Provider Information

NPI Number	:	1316579071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN RENEE MAHESWARAN

Provider Business Mailing Address
First Line	:	1295 KERN RD
Second Line	:
City	:	OAKLAND
State	:	MI
Zip	:	48363-1936
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1295 KERN RD
Second Line	:
City	:	OAKLAND
State	:	MI
Zip	:	48363-1936
Country	:	US
Telephone Number	:	313-378-3788
Fax Number	:

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

Provider Enumeration Date	:	02/10/2020
Last Update Date	:	02/10/2020

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