1659471787 NPI number — LEO R MURSKYJ MD

Table of content: LEO R MURSKYJ MD (NPI 1659471787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659471787 NPI number — LEO R MURSKYJ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MURSKYJ
Provider First Name:
LEO
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1659471787
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 E WATTLES STREET
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-740-8000
Provider Business Mailing Address Fax Number:
248-740-1355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1950 E WATTLES RD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48085-5099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-740-8000
Provider Business Practice Location Address Fax Number:
248-740-1355
Provider Enumeration Date:
09/25/2006

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:  4301050124 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: 4301050124 , 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: 1105005681 . This is a "BCBSMI PERSONAL PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 200158731 . This is a "WARREN TAX ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 381898230 . This is a "SCHOENHERR TAX ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4218953 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110E011830 . This is a "SCHOENHERR BCBS GR PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4749035 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0E00425 . This is a "BLUE CROSS BLUE SHIELD OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700E001650 . This is a "WARREN BCBS GR PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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