1578558318 NPI number — DR. GAIL DIANE SOOHOO-WILLIAMS MD

Table of content: DR. GAIL DIANE SOOHOO-WILLIAMS MD (NPI 1578558318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578558318 NPI number — DR. GAIL DIANE SOOHOO-WILLIAMS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOOHOO-WILLIAMS
Provider First Name:
GAIL
Provider Middle Name:
DIANE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1578558318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43555 DALCOMA DR
Provider Second Line Business Mailing Address:
STE 4
Provider Business Mailing Address City Name:
CLINTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48038-6310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-228-2882
Provider Business Mailing Address Fax Number:
586-463-7152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43555 DALCOMA DR
Provider Second Line Business Practice Location Address:
STE 4
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48038-6310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-228-2882
Provider Business Practice Location Address Fax Number:
586-463-7152
Provider Enumeration Date:
09/19/2005

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: 208100000X , with the licence number:  4301407207 , 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: 0E06114004 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1792650 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2505009741 . This is a "BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C6825 . This is a "M-CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 119983 . This is a "CARE CHOICES-PREFERRED" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: GS407207 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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