Provider Demographics
NPI:1144386053
Name:PROFESSIONAL OBGYN PC
Entity Type:Organization
Organization Name:PROFESSIONAL OBGYN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSHNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-476-4900
Mailing Address - Street 1:20276 MIDDLEBELT RD STE 2
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2054
Mailing Address - Country:US
Mailing Address - Phone:248-476-4900
Mailing Address - Fax:248-476-5435
Practice Address - Street 1:20276 MIDDLEBELT RD
Practice Address - Street 2:SUITE 2
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2054
Practice Address - Country:US
Practice Address - Phone:248-476-4900
Practice Address - Fax:248-476-5435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H24970OtherBCBS GROUP PIN
MIOM91510Medicare ID - Type UnspecifiedGROUP ID