1972375863 NPI number — MICHIGAN INSTITUTE OF UROLOGY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972375863 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:
1972375863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2023
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 STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48081-3203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-771-4820
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 TOWN CENTER DR STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48084-1744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
947-999-8244
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/25/2023

Additional Information

Authorized Official

Authorized Official Last Name:
MCAULEY
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
586-771-4820

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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