1609811918 NPI number — SPORTS MEDICINE ASSOCIATES, PLC

Table of content: (NPI 1609811918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609811918 NPI number — SPORTS MEDICINE ASSOCIATES, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS MEDICINE ASSOCIATES, PLC
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:
1609811918
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
37000 WOODWARD AVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
BLOOMFIELD HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48304-0922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-952-9200
Provider Business Mailing Address Fax Number:
248-952-9201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37000 WOODWARD AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
BLOOMFIELD HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48304-0922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-952-9200
Provider Business Practice Location Address Fax Number:
248-952-9201
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RIFAT
Authorized Official First Name:
SAMI
Authorized Official Middle Name:
F
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
248-952-9200

Provider Taxonomy Codes

  • Taxonomy code: 207QS0010X , with the licence number:  SR056808 , 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: 698099 . This is a "PHCS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 131746 . This is a "PREFERRED CHOICES, MOELLE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P105321 . This is a "BLUE CARE NETWORK, MOELLE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 109591 . This is a "PREFERRED CHOICES, RIFAT" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080F316700 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P85088 . This is a "BLUE CARE NETWORK, RIFAT" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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