1104045384 NPI number — EPG URGENT CARE PLLC

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 1104045384 NPI number — EPG URGENT CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EPG URGENT 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:
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:
1104045384
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
911 E 9 MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERNDALE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48220-1934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-545-7210
Provider Business Mailing Address Fax Number:
248-545-3058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26454 WOODWARD AVE
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
ROYAL OAK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48067-0969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-545-7210
Provider Business Practice Location Address Fax Number:
248-545-1023
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NAMAN
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF MEDICAL DIRECTOR
Authorized Official Telephone Number:
248-544-6236

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 024655 . This is a "MIDWEST FACILITY #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110405384 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00002662456 . This is a "UNITED HEALTH CARE FACILITY #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110F346760 . This is a "BCBS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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