1427208768 NPI number — SOUTHEAST MICHIGAN BRAIN AND SPINE SURGERY, PLLC

Table of content: (NPI 1427208768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427208768 NPI number — SOUTHEAST MICHIGAN BRAIN AND SPINE SURGERY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST MICHIGAN BRAIN AND SPINE SURGERY, PLLC
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:
1427208768
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4800 S SAGINAW ST
Provider Second Line Business Mailing Address:
SUITE 1800
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48507-2669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-732-8336
Provider Business Mailing Address Fax Number:
810-239-4346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 S SAGINAW ST
Provider Second Line Business Practice Location Address:
SUITE 1800
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48507-2669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-732-8336
Provider Business Practice Location Address Fax Number:
810-239-4346
Provider Enumeration Date:
09/23/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ELAOUFIR
Authorized Official First Name:
RKIA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING SPECIALIST
Authorized Official Telephone Number:
810-732-8336

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4301093301 , 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: 1619991023 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4301093301 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".