1215191275 NPI number — ENT SURGICAL ASSOC PC

Table of content: (NPI 1215191275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215191275 NPI number — ENT SURGICAL ASSOC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENT SURGICAL ASSOC 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:
1215191275
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27483 DEQUINDRE RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
MADISON HEIGHTS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48071-5711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-541-0100
Provider Business Mailing Address Fax Number:
248-399-3960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27483 DEQUINDRE RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
MADISON HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48071-5711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-541-0100
Provider Business Practice Location Address Fax Number:
248-399-3960
Provider Enumeration Date:
07/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MILES
Authorized Official First Name:
ILENE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
248-541-1620

Provider Taxonomy Codes

  • Taxonomy code: 237600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4812649 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4985391 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 640F361620 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4812630 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4985355 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5255970 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 640F336900 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4812620 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 640F336900 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4985373 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 540F336540 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 540F336540 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4985364 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4812602 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com