Provider Demographics
NPI:1699004226
Name:ADVANCED OB-GYN OF MICHIGAN
Entity Type:Organization
Organization Name:ADVANCED OB-GYN OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:DESPINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-345-5201
Mailing Address - Street 1:26680 ROSE HILL DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-4572
Mailing Address - Country:US
Mailing Address - Phone:248-345-5201
Mailing Address - Fax:
Practice Address - Street 1:18400 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3588
Practice Address - Country:US
Practice Address - Phone:248-471-9570
Practice Address - Fax:248-471-9603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2012-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty