MEDICARE: JACOB LOGAN GUIMOND DO

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	390200000X	Student in an Organized Health Care Education/Training Program
2	207V00000X	Obstetrics & Gynecology Physician	5151017915	MI

General Provider Information

NPI Number	:	1801642103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB LOGAN GUIMOND DO

Provider Business Mailing Address
First Line	:	22250 PROVIDENCE DR STE 700
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48075-6215
Country	:	US
Telephone Number	:	248-849-3401
Fax Number	:	248-849-4106

Provider Business Practice Location Address
First Line	:	22250 PROVIDENCE DR STE 700
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48075-6215
Country	:	US
Telephone Number	:	248-849-3401
Fax Number	:	248-849-4106

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

Provider Enumeration Date	:	04/26/2024
Last Update Date	:	04/16/2026

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