1588722649 NPI number — S.P.O.R.T. PHYSICIANS, P.C.

Table of content: (NPI 1588722649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588722649 NPI number — S.P.O.R.T. PHYSICIANS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
S.P.O.R.T. PHYSICIANS, P.C.
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:
1588722649
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 E WATTLES RD
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48085-5099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-528-0050
Provider Business Mailing Address Fax Number:
248-528-0909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1950 E WATTLES RD
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48085-5099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-528-0050
Provider Business Practice Location Address Fax Number:
248-528-0909
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOEY
Authorized Official First Name:
JOYCE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
248-528-0050

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4301046108 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 4301406072 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 250F312460 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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