1427049683 NPI number — DR. ALEKSANDER A DOMICZEK MD

Table of content: DR. ALEKSANDER A DOMICZEK MD (NPI 1427049683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427049683 NPI number — DR. ALEKSANDER A DOMICZEK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMICZEK
Provider First Name:
ALEKSANDER
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
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:
1427049683
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6800 E 10 MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTER LINE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48015-1167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-619-9986
Provider Business Mailing Address Fax Number:
586-806-5085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT CLEMENS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-783-2222
Provider Business Practice Location Address Fax Number:
586-783-6280
Provider Enumeration Date:
11/04/2005

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: 207Q00000X , with the licence number:  4301048524 , 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: 0804400591 . This is a "BLUE CROSS INDIVIDUAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080D410020 . This is a "COMMUNITY BLUE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 253226 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: B43001 . This is a "HEALTH NET FEDERAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080D410020 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 92588990011 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080162065 . This is a "METRAHEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080D410020 . This is a "BLUE CROSS POS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4105744 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0805026931 . This is a "BCN IND" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080D410020 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 253226 . This is a "HEALTH ADVANTAGE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4244111 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0805026931 . This is a "BCBS IND" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0988917 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: B43001 . This is a "HEALTH ALLIANCE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C7390 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1427049683 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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