1861434136 NPI number — JORAM O MOGAKA MD PC

Table of content: (NPI 1861434136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861434136 NPI number — JORAM O MOGAKA MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JORAM O MOGAKA MD PC
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:
1861434136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21409 KELLY RD
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
EASTPOINTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48021-3264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-777-0630
Provider Business Mailing Address Fax Number:
586-777-0631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21409 KELLY RD
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
EASTPOINTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48021-3264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-777-0630
Provider Business Practice Location Address Fax Number:
586-777-0631
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOGAKA
Authorized Official First Name:
JORAM
Authorized Official Middle Name:
O
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
586-777-0630

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1255407631 . This is a "INDIVUDAL NPI NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1108235572 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1205126216 . This is a "UNITED FAMILY GR" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1861434136 . This is a "GROUP NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 472234510 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 700H271450 . This is a "UNITED FAMILY BC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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