1184664088 NPI number — JACK DAVID SOBEL MD

Table of content: JACK DAVID SOBEL MD (NPI 1184664088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184664088 NPI number — JACK DAVID SOBEL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOBEL
Provider First Name:
JACK
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1184664088
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1560 E MAPLE RD
Provider Second Line Business Mailing Address:
SUITE 400-CREDENTIALING
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48083-1138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-745-4525
Provider Business Mailing Address Fax Number:
313-577-3223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3750 WOODWARD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201-2007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-745-4525
Provider Business Practice Location Address Fax Number:
313-993-4663
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301049010 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: 4301049010 , 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)





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