1962699843 NPI number — MADISON INTERNISTS P C

Table of content: (NPI 1962699843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962699843 NPI number — MADISON INTERNISTS P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MADISON INTERNISTS P C
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:
1962699843
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3120 CARPENTER ST
Provider Second Line Business Mailing Address:
SUITE 209
Provider Business Mailing Address City Name:
HAMTRAMCK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48212-9802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-891-5437
Provider Business Mailing Address Fax Number:
313-891-0842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27483 DEQUINDRE RD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
MADISON HTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48071-3491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-542-2229
Provider Business Practice Location Address Fax Number:
248-542-2226
Provider Enumeration Date:
09/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHAKOOR
Authorized Official First Name:
SHAKEELA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-797-9063

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  4301078037 , 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: 4998578 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com