1417084161 NPI number — OPTION CARE TROY, LLC

Table of content: (NPI 1417084161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417084161 NPI number — OPTION CARE TROY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTION CARE TROY, LLC
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:
ACTIVE INFUSION
Provider Other Organization Name Type Code:
3
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:
1417084161
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2845 CROOKS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48309-3661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-589-7755
Provider Business Mailing Address Fax Number:
248-589-2644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25219 DEQUINDRE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48071-4211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-589-7755
Provider Business Practice Location Address Fax Number:
248-589-2644
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FILIPPIS
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-829-8282

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4620050 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 540F310380 . This is a "BCBSM DME" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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