1245203454 NPI number — DR. MICHAEL ROBERT ISRAEL MD

Table of content: DR. MICHAEL ROBERT ISRAEL MD (NPI 1245203454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245203454 NPI number — DR. MICHAEL ROBERT ISRAEL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ISRAEL
Provider First Name:
MICHAEL
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
DR.
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:
1245203454
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26901 BEAUMONT BLVD STE 3D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48033-3849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
947-522-1863
Provider Business Mailing Address Fax Number:
47-522-0307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18181 OAKWOOD BLVD STE 212
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48124-5031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-438-7397
Provider Business Practice Location Address Fax Number:
313-438-7398
Provider Enumeration Date:
02/08/2006

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: 2086S0129X , with the licence number:  4301044171 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 4301044171 , 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)

  • Identifier: 020H263670 . This is a "BCBSM GROUP PIN#" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 02-0822061-1 . This is a "BCBSM INDIVIDUAL PIN#" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4235319 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: B9840 . This is a "MCARE INDIVIDUAL PIN#" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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