MEDICARE: MRS. KIMBERLY T CANTILLON PA

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	363AM0700X	Medical Physician Assistant	5601004760	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5301004760	OTHER	MI	LICENSE

General Provider Information

NPI Number	:	1740218999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY T CANTILLON PA

Provider Business Mailing Address
First Line	:	39450 W 12 MILE RD
Second Line	:
City	:	NOVI
State	:	MI
Zip	:	48377-3600
Country	:	US
Telephone Number	:	313-461-4632
Fax Number	:

Provider Business Practice Location Address
First Line	:	39450 W 12 MILE RD
Second Line	:
City	:	NOVI
State	:	MI
Zip	:	48377-3600
Country	:	US
Telephone Number	:	313-461-4632
Fax Number	:

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	01/28/2021

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