1730167644 NPI number — BORIVOJE TRIFUNOVIC MD

Table of content: BORIVOJE TRIFUNOVIC MD (NPI 1730167644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730167644 NPI number — BORIVOJE TRIFUNOVIC MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRIFUNOVIC
Provider First Name:
BORIVOJE
Provider Middle Name:
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:
1730167644
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25710 KELLY RD
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48066-4959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-772-2600
Provider Business Mailing Address Fax Number:
586-772-5289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25710 KELLY RD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48066-4959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-772-2600
Provider Business Practice Location Address Fax Number:
586-772-5289
Provider Enumeration Date:
01/03/2006

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:  4301080193 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208M00000X , with the licence number: 4301080193 , 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: 4772374 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1730167644 . This is a "NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4784212 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com