Basic Information
| Provider Information | |||||||||
| NPI: | 1689136152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGAN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD STE 3D | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221865 | ||||||||
| FaxNumber: | 9475220307 | ||||||||
| Practice Location | |||||||||
| Address1: | 17392 W 13 MILE RD | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480255438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486468166 | ||||||||
| FaxNumber: | 2486468176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2019 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101026823 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.