1003125774 NPI number — ENVISION MEDICAL GROUP PLLC

Table of content: (NPI 1003125774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003125774 NPI number — ENVISION MEDICAL GROUP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENVISION MEDICAL GROUP PLLC
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:
1003125774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27275 HAGGERTY RD STE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOVI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48377-3635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-741-6901
Provider Business Mailing Address Fax Number:
248-721-8203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12660 TEN MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH LYON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48178-9141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-348-1131
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WAYNE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
248-348-8700

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213EP1101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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