1235281916 NPI number — PRIMECARE OF NOVI PLLC

Table of content: (NPI 1235281916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235281916 NPI number — PRIMECARE OF NOVI PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMECARE OF NOVI 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:
1235281916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39555 WEST TEN MILE RD
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
NOVI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48375-2950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-426-7200
Provider Business Mailing Address Fax Number:
248-426-7335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39555 WEST TEN MILE RD
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
NOVI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48375-2950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-426-7200
Provider Business Practice Location Address Fax Number:
248-426-7335
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHIVELY
Authorized Official First Name:
THEODORE
Authorized Official Middle Name:
W
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
248-426-7200

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0F316970 . This is a "BLUE CROSS BLUE SHIELD MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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