1043201288 NPI number — MRS. DOROTA MELLER KLENK RN NP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043201288 NPI number — MRS. DOROTA MELLER KLENK RN NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLENK
Provider First Name:
DOROTA
Provider Middle Name:
MELLER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MELLER
Provider Other First Name:
DOROTA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043201288
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6777 W. MAPLE RD
Provider Second Line Business Mailing Address:
DEPT OF SURGERY
Provider Business Mailing Address City Name:
WEST BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48322-3031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6777 W. MAPLE RD
Provider Second Line Business Practice Location Address:
DEPT OF SURGERY
Provider Business Practice Location Address City Name:
WEST BLOOMFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-910-0061
Provider Business Practice Location Address Fax Number:
248-849-3230
Provider Enumeration Date:
11/04/2005

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: 363L00000X , with the licence number:  4704231031 , 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)





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