1104045384 NPI number — EPG URGENT CARE PLLC

Table of content: (NPI 1104045384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104045384 NPI number — EPG URGENT CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EPG URGENT CARE 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:
1104045384
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
911 E 9 MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERNDALE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48220-1934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-545-7210
Provider Business Mailing Address Fax Number:
248-545-3058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26454 WOODWARD AVE
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
ROYAL OAK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48067-0969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-545-7210
Provider Business Practice Location Address Fax Number:
248-545-1023
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NAMAN
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF MEDICAL DIRECTOR
Authorized Official Telephone Number:
248-544-6236

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , 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: 024655 . This is a "MIDWEST FACILITY #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110405384 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00002662456 . This is a "UNITED HEALTH CARE FACILITY #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110F346760 . This is a "BCBS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com