1922193960 NPI number — METROPOLITAN MEDICAL CENTER PLLC

Table of content: (NPI 1922193960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922193960 NPI number — METROPOLITAN MEDICAL CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METROPOLITAN MEDICAL CENTER PLLC
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:
1922193960
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9230 JOSEPH CAMPAU ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMTRAMCK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48212-3731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-875-9270
Provider Business Mailing Address Fax Number:
313-875-9420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9230 JOSEPH CAMPAU ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMTRAMCK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48212-3731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-875-9270
Provider Business Practice Location Address Fax Number:
313-875-9420
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIETRZYKOWSKI
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
313-875-9270

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301063858 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084N0400X , with the licence number: 4301081423 , 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: 110H241220 . This is a "BCBS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110H241220 . This is a "BCN GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 151659 . This is a "GREAT LAKES HEALTH CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1922193960 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 022808 . This is a "MIDWEST HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 35949 . This is a "HEALTH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5458769 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 000000001426 . This is a "CAPE HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: DO5413 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1108269932 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C6560 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: G76852 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104391529 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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