1366526378 NPI number — MARIDEL HERNANDEZ INTERNAL MEDICINE PC

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 1366526378 NPI number — MARIDEL HERNANDEZ INTERNAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIDEL HERNANDEZ INTERNAL MEDICINE PC
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:
1366526378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
131 KERCHEVAL AVE
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
GROSSE POINTE FARMS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48236-3629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-640-8400
Provider Business Mailing Address Fax Number:
313-640-9232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 KERCHEVAL AVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
GROSSE POINTE FARMS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48236-3629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-640-8400
Provider Business Practice Location Address Fax Number:
313-640-9232
Provider Enumeration Date:
10/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
MARIDEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER CEO
Authorized Official Telephone Number:
313-640-8400

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  5101012021 , 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: 0E02258 . This is a "BCBS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1158213464 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4869383-11 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".