1093941171 NPI number — PEYMAN KABOLIZADEH

Table of content: PEYMAN KABOLIZADEH (NPI 1093941171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093941171 NPI number — PEYMAN KABOLIZADEH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KABOLIZADEH
Provider First Name:
PEYMAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093941171
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 TOWN CENTER DR STE 203
Provider Second Line Business Mailing Address:
BEAUMONT MEDICAL STAFF AFFAIRS
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48084-1744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3577 W 13 MILE RD
Provider Second Line Business Practice Location Address:
BEAUMONT RADIATION ONCOLOGY ROYAL OAK
Provider Business Practice Location Address City Name:
ROYAL OAK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48073-6710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-551-5490
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: 4301107331 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0F34985 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".