1578909271 NPI number — MRS. ANDREA MARIE-GIMBOSA CHILDERS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578909271 NPI number — MRS. ANDREA MARIE-GIMBOSA CHILDERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHILDERS
Provider First Name:
ANDREA
Provider Middle Name:
MARIE-GIMBOSA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAITLAND
Provider Other First Name:
ANDREA
Provider Other Middle Name:
MARIE-GIMBOSA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.O.T., O.T.R.L.,
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578909271
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1604 WITHERBEE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48084-2684
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-491-4430
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 STEPHENSON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48083-1110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-616-0950
Provider Business Practice Location Address Fax Number:
734-893-3154
Provider Enumeration Date:
05/21/2013

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: 225X00000X , with the licence number:  5201007137 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225XN1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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