Basic Information
| Provider Information | |||||||||
| NPI: | 1407571433 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AQUINO INTEGRATIVE INTERNAL MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 726 WESTCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | GROSSE POINTE PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482301826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139296407 | ||||||||
| FaxNumber: | 3136726241 | ||||||||
| Practice Location | |||||||||
| Address1: | 7633 E JEFFERSON AVE STE 170 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482143731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134010256 | ||||||||
| FaxNumber: | 3136726241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2022 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | AQUINO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | DO, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3134010256 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1780671461 | 05 | MI | MEDICAID | MI4989600 | 01 | MI | OTHER | OTHER | H50533 | 05 | MI | MEDICAID |