1801030218 NPI number — MICHIGAN REPRODUCTIVE MEDICINE

Table of content: (NPI 1801030218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801030218 NPI number — MICHIGAN REPRODUCTIVE MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN REPRODUCTIVE MEDICINE
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:
CENTER FOR REPRODUCTIVE MEDICINE AND SURGERY, PC
Provider Other Organization Name Type Code:
4
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:
1801030218
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2830 MEADOWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48302-1029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-972-0877
Provider Business Mailing Address Fax Number:
248-972-0880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41000 WOODWARD AVE
Provider Second Line Business Practice Location Address:
SUITE 100 EAST
Provider Business Practice Location Address City Name:
BLOOMFIELD HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48304-5130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-593-6990
Provider Business Practice Location Address Fax Number:
248-593-5925
Provider Enumeration Date:
04/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MERSOL-BARG
Authorized Official First Name:
MARY JO
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
248-972-0877

Provider Taxonomy Codes

  • Taxonomy code: 207VE0102X , with the licence number:  MM0056302 , 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: 14367A . This is a "HEALTH ALLIANCE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0633272 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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