1013132240 NPI number — INFINITY PRIMARY CARE PLLC

Table of content: (NPI 1013132240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013132240 NPI number — INFINITY PRIMARY CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INFINITY PRIMARY CARE 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:
6
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:
1013132240
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17197 N LAUREL PARK DR
Provider Second Line Business Mailing Address:
SUITE 540
Provider Business Mailing Address City Name:
LIVONIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48152-2680
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-853-4901
Provider Business Mailing Address Fax Number:
734-853-4900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20276 MIDDLEBELT
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
LIVONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48152-2054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-477-8000
Provider Business Practice Location Address Fax Number:
248-477-8300
Provider Enumeration Date:
04/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEIGHTON
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
734-432-7581

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110H222740 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110H22740 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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