1780779330 NPI number — DR. SUDJONO KOSIM MD

Table of content: DR. SUDJONO KOSIM MD (NPI 1780779330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780779330 NPI number — DR. SUDJONO KOSIM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOSIM
Provider First Name:
SUDJONO
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIM
Provider Other First Name:
HONG T JAY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780779330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
718 N. MACOMB
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-240-8400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
718 N. MACOMB
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-240-8400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2006

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: 2085R0202X , with the licence number:  4301040246 , 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: 12915 . This is a "COMMUNITY CHOICE OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3442516 . This is a "HEALTH PLAN OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3442490 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3442516 . This is a "MOLINA HEALTHCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 802982 . This is a "COMMUNITY CARE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 38338429803 . This is a "CNA HEALTH SERVICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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