1285118919 NPI number — AMANDA M MASTROFINI NP

Table of content: AMANDA M MASTROFINI NP (NPI 1285118919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285118919 NPI number — AMANDA M MASTROFINI NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASTROFINI
Provider First Name:
AMANDA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1285118919
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29992 NORTHWESTERN HWY STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48334-3292
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-851-1430
Provider Business Mailing Address Fax Number:
248-851-5182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3577 W 13 MILE RD STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROYAL OAK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48073-6710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-551-2446
Provider Business Practice Location Address Fax Number:
248-551-1094
Provider Enumeration Date:
09/19/2018

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: 363LG0600X , with the licence number:  4704288346 , 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: 1285118919 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4704288346 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: MI4989654 . This is a "MEDICARE PROVIDER NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com