1255325684 NPI number — RODERICK CLAYBROOKS MD

Table of content: RODERICK CLAYBROOKS MD (NPI 1255325684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255325684 NPI number — RODERICK CLAYBROOKS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLAYBROOKS
Provider First Name:
RODERICK
Provider Middle Name:
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:
1255325684
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22250 PROVIDENCE DR
Provider Second Line Business Mailing Address:
SUITE 601
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48075-4825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-569-7745
Provider Business Mailing Address Fax Number:
248-569-4539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22250 PROVIDENCE DR
Provider Second Line Business Practice Location Address:
SUITE 601
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48075-4825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-569-7745
Provider Business Practice Location Address Fax Number:
248-569-4539
Provider Enumeration Date:
08/31/2005

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: 207XS0117X , with the licence number:  4301074231 , 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: 4781570 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7542611 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 12897 . This is a "CAPE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 141817 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00271654 . This is a "RDMC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 17348 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: RC074231 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 024520 . This is a "MIDWEST" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 59938 . This is a "OMNICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 630511 . This is a "BLUE CROSS NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: TAX I.D. . This is a "20-0440211" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 607926000 . This is a "OCWP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 150941 . This is a "GREAT LAKES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 111628500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com