1225138340 NPI number — DR. MARSHALL KEVIN MEDLEY D.O.

Table of content: DR. MARSHALL KEVIN MEDLEY D.O. (NPI 1225138340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225138340 NPI number — DR. MARSHALL KEVIN MEDLEY D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDLEY
Provider First Name:
MARSHALL
Provider Middle Name:
KEVIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1225138340
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26901 BEAUMONT BLVD STE 3D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48033-3849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35600 CENTRAL CITY PKWY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WESTLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48185-2046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-421-1000
Provider Business Practice Location Address Fax Number:
734-421-1001
Provider Enumeration Date:
09/25/2006

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: 2086S0129X , with the licence number:  5101013769 , 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: 141412 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4774341 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0007367710 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5821256 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: U92085 . This is a "PRIVATE HEALTH CARE SYSTE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 000000012192 . This is a "CAPE HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 17178 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P36227-F . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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