1508964511 NPI number — OAKLAND GASTROENTEROLOGY ASSOCIATES, P.C.

Table of content: (NPI 1508964511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508964511 NPI number — OAKLAND GASTROENTEROLOGY ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAKLAND GASTROENTEROLOGY ASSOCIATES, P.C.
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:
1508964511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3535 W 13 MILE RD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
ROYAL OAK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48073-6770
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-551-0900
Provider Business Mailing Address Fax Number:
248-551-0905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 W 13 MILE RD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
ROYAL OAK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48073-6770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-551-0900
Provider Business Practice Location Address Fax Number:
248-551-0905
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POLIDORI
Authorized Official First Name:
GREGG
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-551-0900

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  4301044285 , 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: 100F37143 . This is a "BCBS AND BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4101048 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4310182 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2836211 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4257370 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3364901 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4258298 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4257380 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4340978 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4340940 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4592984 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2836230 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4318636 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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