1609836204 NPI number — MEDILODGE OF ROCHESTER HILLS INC

Table of content: (NPI 1609836204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609836204 NPI number — MEDILODGE OF ROCHESTER HILLS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDILODGE OF ROCHESTER HILLS INC
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:
MEDILODGE OF ROCHESTER HILLS
Provider Other Organization Name Type Code:
3
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:
1609836204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7400 NEW LA GRANGE RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40222-4870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-429-8062
Provider Business Mailing Address Fax Number:
502-429-0650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1480 WALTON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48309-1739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-651-4422
Provider Business Practice Location Address Fax Number:
248-651-3009
Provider Enumeration Date:
03/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROGERS
Authorized Official First Name:
STACEY
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
502-429-8062

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1609836204 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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