1366484693 NPI number — MICHELE PENNINGTON MD FAMILY MEDICAL PLLC

Table of content: (NPI 1366484693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366484693 NPI number — MICHELE PENNINGTON MD FAMILY MEDICAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHELE PENNINGTON MD FAMILY MEDICAL 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:
1366484693
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
#6620 6620 RELIABLE PARKWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60686-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-304-9400
Provider Business Mailing Address Fax Number:
248-304-9401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25775 W 10 MILE RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48034-4856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-304-9400
Provider Business Practice Location Address Fax Number:
248-304-9401
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PENNINGTON
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
248-304-9400

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4301070192 , 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: 0801975377 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0806346602 . This is a "BCBC BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com