1801978309 NPI number — MICHIGAN INSTITUTE OF UROLOGY PC

Table of content: (NPI 1801978309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801978309 NPI number — MICHIGAN INSTITUTE OF UROLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN INSTITUTE OF UROLOGY PC
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:
1801978309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20952 E 12 MILE RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SAINT CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48081-3200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-771-4820
Provider Business Mailing Address Fax Number:
586-771-6620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 HAGGERTY ROAD
Provider Second Line Business Practice Location Address:
SUITE 2000
Provider Business Practice Location Address City Name:
WEST BLOOMFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48323-2102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-624-9900
Provider Business Practice Location Address Fax Number:
248-896-5450
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SANTINO
Authorized Official First Name:
ALPHONSE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
586-771-4820

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2088P0231X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 540E016120 . This is a "BCBSM DME" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CB9133 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 340E062730 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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