Provider Demographics
NPI:1164556692
Name:ELLENBERG, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:ELLENBERG
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 1:28455 HAGGERTY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2982
Mailing Address - Country:US
Mailing Address - Phone:248-893-3200
Mailing Address - Fax:248-893-2950
Practice Address - Street 1:28455 HAGGERTY RD
Practice Address - Street 2:200
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2982
Practice Address - Country:US
Practice Address - Phone:248-893-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086085208100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9310121OtherBCBSM PIN
MI4301086085OtherSTATE LISC
MI0Q26007055Medicare PIN