Provider Demographics
NPI:1558456657
Name:ADVANCED HEALTHCARE FOR WOMEN PC
Entity Type:Organization
Organization Name:ADVANCED HEALTHCARE FOR WOMEN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MICKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-822-6200
Mailing Address - Street 1:1777 AXTELL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084
Mailing Address - Country:US
Mailing Address - Phone:248-822-6200
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL
Practice Address - Street 2:SUITE 102
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084
Practice Address - Country:US
Practice Address - Phone:248-822-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIIM043839207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160F318220OtherBCBS OF MICHIGAN
MIB46469Medicare UPIN
MI160F318220OtherBCBS OF MICHIGAN
MIC3195OtherMCARE
MIB46469Medicare UPIN
MI160F318220OtherBCBS OF MICHIGAN
MI0N32150002Medicare ID - Type Unspecified