1053306886 NPI number — DR. BRIGITTE MASENGU NGOYI MD

Table of content: DR. BRIGITTE MASENGU NGOYI MD (NPI 1053306886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053306886 NPI number — DR. BRIGITTE MASENGU NGOYI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NGOYI
Provider First Name:
BRIGITTE
Provider Middle Name:
MASENGU
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MASENGU
Provider Other First Name:
BRIGITTE
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:
1053306886
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 806070
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-777-2550
Provider Business Mailing Address Fax Number:
586-777-2447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22050 GREATER MACK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-777-2550
Provider Business Practice Location Address Fax Number:
586-777-2447
Provider Enumeration Date:
09/19/2005

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: 207V00000X , with the licence number:  4301407585 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: BN407585 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2652582 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4301407585 . This is a "CONTROLLED SUBSTANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: C3423 . This is a "M CARE PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4847009 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: C0HRJ . This is a "CLEARING HOUSE SUBMITTER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1608252141 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 117658 . This is a "GREAT LAKES" identifier . This identifiers is of the category "OTHER".




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