1336396142 NPI number — MIDWEST MEDICAL MANAGEMENT

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 1336396142 NPI number — MIDWEST MEDICAL MANAGEMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST MEDICAL MANAGEMENT
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:
6
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:
1336396142
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6689 ORCHARD LAKE RD
Provider Second Line Business Mailing Address:
SUITE 268
Provider Business Mailing Address City Name:
WEST BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48322-3404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-894-6647
Provider Business Mailing Address Fax Number:
248-682-2828

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
G-3422 FLUSHING RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-894-6647
Provider Business Practice Location Address Fax Number:
248-682-2828
Provider Enumeration Date:
08/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TWIGG
Authorized Official First Name:
LEWIS
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
248-894-6647

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 160H21777 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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