1699724559 NPI number — RIVERSIDE OB GYN P C

Table of content: (NPI 1699724559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699724559 NPI number — RIVERSIDE OB GYN P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE OB GYN P C
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:
1699724559
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2275 W JEFFERSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRENTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48183-2114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-675-7210
Provider Business Mailing Address Fax Number:
734-675-3023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2275 W JEFFERSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRENTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48183-2114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-675-7210
Provider Business Practice Location Address Fax Number:
734-675-3023
Provider Enumeration Date:
05/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AL-JERDI
Authorized Official First Name:
AHMAD
Authorized Official Middle Name:
I.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
734-675-7210

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 160055737 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4471183-11 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1540358-11 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 160003353 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2966851 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 160055739 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 160059461 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 160H210680 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 6676861 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4165045-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7139017 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4106545-11 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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