1528480365 NPI number — COMORIN KIDNEYCARE PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528480365 NPI number — COMORIN KIDNEYCARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMORIN KIDNEYCARE 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:
1528480365
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 510052
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVONIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48151-6052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-288-3370
Provider Business Mailing Address Fax Number:
734-785-8421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14555 LEVAN ROAD
Provider Second Line Business Practice Location Address:
SUITE 308
Provider Business Practice Location Address City Name:
LIVONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48154-6052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-288-3370
Provider Business Practice Location Address Fax Number:
734-785-8421
Provider Enumeration Date:
01/14/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GREENWOOD
Authorized Official First Name:
VICTORIA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
BILLER
Authorized Official Telephone Number:
313-221-5152

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  4301084038 , 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: 4301084038 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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