1518917533 NPI number — ENRIQUE URDANIVIA

Table of content: ENRIQUE URDANIVIA (NPI 1518917533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518917533 NPI number — ENRIQUE URDANIVIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
URDANIVIA
Provider First Name:
ENRIQUE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1518917533
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3234 MONTMARTE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
W BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48323-3541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-737-8043
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4700 SCHAEFER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48126-3698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-581-2600
Provider Business Practice Location Address Fax Number:
313-581-0228
Provider Enumeration Date:
05/11/2006

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: 207R00000X , with the licence number:  4301037751 , 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: 236661 . This is a "MEDICARE PROVIDER NO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 001007 . This is a "MIDWEST HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 123355 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 50805 . This is a "OMNICARE HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: B42918 . This is a "HEALTH ALLIANCE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 101379155 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4558034 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110Q262840 . This is a "BCBSM/BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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