1942272364 NPI number — MICHIGAN OPHTHALMOLOGY SPECIALISTS, PLLC

Table of content: (NPI 1942272364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942272364 NPI number — MICHIGAN OPHTHALMOLOGY SPECIALISTS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN OPHTHALMOLOGY SPECIALISTS, 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:
COBURN KLEINFELDT EYE CLINIC 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:
1942272364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30150 TELEGRAPH RD STE 271
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BINGHAM FARMS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48025-4521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-395-5175
Provider Business Mailing Address Fax Number:
248-395-5170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33400 6 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48152-3165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-421-2020
Provider Business Practice Location Address Fax Number:
734-421-2290
Provider Enumeration Date:
02/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KLEINFELDT
Authorized Official First Name:
NOSSONAL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
734-421-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0M94750 . This is a "WPS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C30473 . This is a "PALMETTO GBA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104983299 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104638662 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104966799 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180H270190 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104485008 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180H270190 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 58117A . This is a "HEALTH ALLIANCE PLAN OF M" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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