Provider Demographics
NPI:1902072952
Name:MICHIGAN COSMETIC & RECONSTRUCTIVE SURGERY PLLC
Entity Type:Organization
Organization Name:MICHIGAN COSMETIC & RECONSTRUCTIVE SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:AWADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-948-5500
Mailing Address - Street 1:PO BOX 673053
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-3053
Mailing Address - Country:US
Mailing Address - Phone:248-948-5500
Mailing Address - Fax:248-948-8085
Practice Address - Street 1:29110 INKSTER RD
Practice Address - Street 2:STE 250
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1098
Practice Address - Country:US
Practice Address - Phone:248-948-5500
Practice Address - Fax:248-948-8085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty