1194720276 NPI number — STUART R GILDENBERG MD

Table of content: STUART R GILDENBERG MD (NPI 1194720276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194720276 NPI number — STUART R GILDENBERG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILDENBERG
Provider First Name:
STUART
Provider Middle Name:
R
Provider Name Prefix Text:
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:
1194720276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11900 E 12 MILE RD
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48093-3490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-574-2800
Provider Business Mailing Address Fax Number:
586-574-2803

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11900 E 12 MILE RD
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48093-3490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-574-2800
Provider Business Practice Location Address Fax Number:
586-574-2803
Provider Enumeration Date:
06/16/2005

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: 207N00000X , with the licence number:  4301407085 , 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: 100784 . This is a "MOLINA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1222960001 . This is a "TOTAL HEALTH CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00180380 . This is a "TRAVELERS MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 070E15730 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: SG407085 . This is a "BLUE CARE NETWORK ADVANTA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1222960001 . This is a "MIDWEST HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 29183 . This is a "COMMUNITY CHOICE OF MICHI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4640517 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: C3726 . This is a "MCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 070E015730 . This is a "BCN ADVANTAGE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110028 . This is a "CARER CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 200330360 . This is a "HEALTH PLUS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4358234 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4358234 . This is a "AETNA HMO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0N96970006 . This is a "BCBSM MEDICARE PLUS BLUE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 100962 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110028 . This is a "PREFERRED PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: F00397 . This is a "HAP HMO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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