1407122575 NPI number — BRUCE MILLMAN, D.O., PLLC

Table of content: (NPI 1407122575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407122575 NPI number — BRUCE MILLMAN, D.O., PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRUCE MILLMAN, D.O., PLLC
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:
1407122575
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2221 LIVERNOIS RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48083-1603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-586-4877
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2221 LIVERNOIS RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48083-1603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-586-4877
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MILLMAN
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
877-586-4877

Provider Taxonomy Codes

  • Taxonomy code: 207RC0200X , with the licence number:  BM012972 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 5101012972 , 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: 14395 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: PTAN INDIVI MI591001 . This is a "MEDICARE WPS WISCONSIN FOR MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2956312664 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: PTAN GROUP DT6533 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: GROUP PTAN IS MI5981 . This is a "MEDICARE WPS WISCONSIN FOR MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00241562 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2956312664 . This is a "BLUE CARE NETWORK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4711548 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: H57094 . This is a "HAP" identifier . This identifiers is of the category "OTHER".




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