Provider Demographics
NPI:1770021354
Name:SOUTHFIELD OBSTERICAL AND GYNECOLOGIC INSTITUTE P.C.
Entity Type:Organization
Organization Name:SOUTHFIELD OBSTERICAL AND GYNECOLOGIC INSTITUTE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAROLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-354-2201
Mailing Address - Street 1:29275 NORTHWESTERN HWY STE 207
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-5744
Mailing Address - Country:US
Mailing Address - Phone:248-354-2201
Mailing Address - Fax:248-354-2220
Practice Address - Street 1:29275 NORTHWESTERN HWY STE 207
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-5744
Practice Address - Country:US
Practice Address - Phone:248-354-2201
Practice Address - Fax:248-354-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPH054677207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4197245Medicaid
F68743Medicare UPIN
MI4197245Medicaid