1194011643 NPI number — OAKLAND DIGESTIVE DISEASE,PLLC

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 1194011643 NPI number — OAKLAND DIGESTIVE DISEASE,PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAKLAND DIGESTIVE DISEASE,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:
1194011643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4455 WOODWARD AVE
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
PONTIAC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48341-5022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-858-3878
Provider Business Mailing Address Fax Number:
248-209-6777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44555 WOODWARD AVE
Provider Second Line Business Practice Location Address:
STE 304
Provider Business Practice Location Address City Name:
PONTIAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48341-5035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-858-3878
Provider Business Practice Location Address Fax Number:
248-209-6777
Provider Enumeration Date:
06/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MARKLE
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MEDICAL DOCTOR
Authorized Official Telephone Number:
248-858-3878

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4301091849 , 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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