MEDICARE: PROFESSIONAL OBGYN PC

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	207V00000X	Obstetrics & Gynecology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0H24970	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1477602480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL OBGYN PC

Provider Business Mailing Address
First Line	:	20276 MIDDLEBELT RD
Second Line	:	SUITE 2
City	:	LIVONIA
State	:	MI
Zip	:	48152-2054
Country	:	US
Telephone Number	:	248-476-4900
Fax Number	:	248-476-5435

Provider Business Practice Location Address
First Line	:	55 N POND DR
Second Line	:	SUITE 2
City	:	WALLED LAKE
State	:	MI
Zip	:	48390-3080
Country	:	US
Telephone Number	:	248-624-3366
Fax Number	:	248-624-0127

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROGER KUSHNER
Credential	:	D.O.
Telephone Number	:	248-476-4900

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	08/22/2020

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