1205835931 NPI number — ARBOR LANE FAMILY PHYSICIANS PLC

Table of content: (NPI 1205835931)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205835931 NPI number — ARBOR LANE FAMILY PHYSICIANS PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARBOR LANE FAMILY PHYSICIANS PLC
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:
1205835931
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8555 N SILVERY LN
Provider Second Line Business Mailing Address:
SUITE C302
Provider Business Mailing Address City Name:
DEARBORN HEIGHTS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48127-1379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-561-0550
Provider Business Mailing Address Fax Number:
313-561-3646

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8555 N SILVERY LN
Provider Second Line Business Practice Location Address:
SUITE C302
Provider Business Practice Location Address City Name:
DEARBORN HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48127-1379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-561-0550
Provider Business Practice Location Address Fax Number:
313-561-3646
Provider Enumeration Date:
07/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GAZELLA
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
313-561-0550

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  GG034127 , 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: 4492601 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4492586 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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