1982714903 NPI number — LOUIS J GELLER DPM PC

Table of content: (NPI 1982714903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982714903 NPI number — LOUIS J GELLER DPM PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOUIS J GELLER DPM 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:
GELLER FOOT CLINIC
Provider Other Organization Name Type Code:
3
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:
1982714903
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25841 PEMBROKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON WOODS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48070-1621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-353-0096
Provider Business Mailing Address Fax Number:
248-809-6255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28460 SOUTHFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LATHRUP VILLAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48076-2820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-353-0096
Provider Business Practice Location Address Fax Number:
248-809-6255
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GELLER
Authorized Official First Name:
LOUIS
Authorized Official Middle Name:
JEREMY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-353-0096

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  5901001926 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X , with the licence number: 0524 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4627620001 . This is a "DMERC LICENSE NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: ON53230 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101026 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2430677 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4856352050 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4431259 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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