1336252857 NPI number — PODIATRY EXAMINERS OF MICHIGAN PC

Table of content: (NPI 1336252857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336252857 NPI number — PODIATRY EXAMINERS OF MICHIGAN PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PODIATRY EXAMINERS OF MICHIGAN 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:
1336252857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3800 WOODWARD AVENUE
Provider Second Line Business Mailing Address:
SUITE 318
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48201-2066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-833-3096
Provider Business Mailing Address Fax Number:
313-833-7843

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3800 WOODWARD AVENUE
Provider Second Line Business Practice Location Address:
SUITE 318
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201-2066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-833-3096
Provider Business Practice Location Address Fax Number:
313-833-7843
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GASTWIRTH
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
MARSHALL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
313-833-3090

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  0814 , 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: 0961720001 . This is a "DMERC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: U23902 . This is a "HEALTH ALLIANCE PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4888250510 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 002631 . This is a "MIDWEST HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1260775 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15982 . This is a "CAPE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 123985 . This is a "WELLNESS PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 20094 . This is a "OMICARE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00248 . This is a "HUMANA CHOICE CARE" identifier . This identifiers is of the category "OTHER".




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