1114019627 NPI number — DR. MICHAEL S FOZO MD

Table of content: DR. MICHAEL S FOZO MD (NPI 1114019627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114019627 NPI number — DR. MICHAEL S FOZO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOZO
Provider First Name:
MICHAEL
Provider Middle Name:
S
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:
1114019627
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21000 E 12 MILE RD
Provider Second Line Business Mailing Address:
STE 111
Provider Business Mailing Address City Name:
ST CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-779-7610
Provider Business Mailing Address Fax Number:
586-445-2523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21000 E 12 MILE RD
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
SAINT CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48081-1116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-779-7610
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2006

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: 207YX0007X , with the licence number:  MF075562 , 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: 4339229 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: H68407 . This is a "HEALTH ALLIANCE PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0501379 . This is a "BLUE CARE NETWORK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4505853 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 136815 . This is a "CARE CHOICES" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00014677 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 141736 . This is a "GREAT LAKES HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 16056 . This is a "MCAR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6029816 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".




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