1255573564 NPI number — MIDWEST URGENT CARE CENTER PC

Table of content: (NPI 1255573564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255573564 NPI number — MIDWEST URGENT CARE CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST URGENT CARE CENTER PC
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:
1255573564
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3054
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48333-3054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-592-6330
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15540 BEECH DALY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48239-3804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-592-6330
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
VLACHOS
Authorized Official First Name:
DARRELL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
313-592-6330

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0H20597 . This is a "BLUE CROSS BLUE SHIELD O MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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