Basic Information
| Provider Information | |||||||||
| NPI: | 1164694113 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7148 RELIABLE PKWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487921779 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4727 SAINT ANTOINE ST | ||||||||
| Address2: | STE 304 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482011461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137450499 | ||||||||
| FaxNumber: | 3138338801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2008 | ||||||||
| LastUpdateDate: | 09/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | BH26634488101 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 4301090814 | 01 | MI | LICENSE | OTHER | 1164694113 | 05 | MI | MEDICAID |