1003055252 NPI number — DR. OLIVER DIMITRIJEVIC MD

Table of content: DR. OLIVER DIMITRIJEVIC MD (NPI 1003055252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003055252 NPI number — DR. OLIVER DIMITRIJEVIC MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIMITRIJEVIC
Provider First Name:
OLIVER
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:
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:
1003055252
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19251 MACK AVE
Provider Second Line Business Mailing Address:
SUITE 333
Provider Business Mailing Address City Name:
GROSSE POINTE WOODS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48236-2893
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-343-7280
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27450 SCHOENHERR RD
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48088-6683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-582-7632
Provider Business Practice Location Address Fax Number:
586-582-7633
Provider Enumeration Date:
02/11/2009

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: 208M00000X , with the licence number:  01079000A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 4301089472 , 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: 700E012740 . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110474500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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