1578513206 NPI number — MILAN URGENT CARE CLINIC PLLC

Table of content: (NPI 1578513206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578513206 NPI number — MILAN URGENT CARE CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILAN URGENT CARE CLINIC 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:
1578513206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48160-1248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-439-2388
Provider Business Mailing Address Fax Number:
734-439-1384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48160-1248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-439-2388
Provider Business Practice Location Address Fax Number:
734-439-1384
Provider Enumeration Date:
05/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DIAZ
Authorized Official First Name:
IAN-CROMWELL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
734-439-2388

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ID076711 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: JB024426 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0805810592 . This is a "DR. BERSALONA BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0805810602 . This is a "DR. DIAZ BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".