Provider Demographics
NPI:1154301018
Name:HENOCH, MALCOLM (MD)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:
Last Name:HENOCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15492 BAY HILL DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-8474
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18181 OAKWOOD BLVD
Practice Address - Street 2:SUITE 402
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-5032
Practice Address - Country:US
Practice Address - Phone:313-996-7380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077215207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B96477Medicare UPIN