Basic Information
| Provider Information | |||||||||
| NPI: | 1962862508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERWIN | ||||||||
| FirstName: | MARLA | ||||||||
| MiddleName: | BLAIR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2115 WATKINS LAKE RD | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483281435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487637830 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3990 JOHN R ST | ||||||||
| Address2: | BOX 162 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137457233 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2016 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | 5101025706 | MI | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | 5101025706 | MI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.