1144524133 NPI number — BIRMINGHAM MAPLE CLINIC

Table of content: (NPI 1144524133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144524133 NPI number — BIRMINGHAM MAPLE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIRMINGHAM MAPLE CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1144524133
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2075 W BIG BEAVER RD
Provider Second Line Business Mailing Address:
SUITE 520
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48084-3407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-646-6659
Provider Business Mailing Address Fax Number:
248-642-8645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2075 W BIG BEAVER RD
Provider Second Line Business Practice Location Address:
SUITE 520
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48084-3407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-646-6659
Provider Business Practice Location Address Fax Number:
248-642-8645
Provider Enumeration Date:
01/05/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EDELSON
Authorized Official First Name:
LORI
Authorized Official Middle Name:
KANAT
Authorized Official Title or Position:
BUSINESS OWNER
Authorized Official Telephone Number:
248-646-6659

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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