1386625143 NPI number — SOUTHFIELD REHABILITATION COMPANY

Table of content: (NPI 1386625143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386625143 NPI number — SOUTHFIELD REHABILITATION COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHFIELD REHABILITATION COMPANY
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:
6
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:
1386625143
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
06/04/2008
NPI Reactivation Date:
07/15/2008

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 674073
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48267-4073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-582-0864
Provider Business Mailing Address Fax Number:
586-576-0393

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22401 FOSTER WINTER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48075-3724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-423-5100
Provider Business Practice Location Address Fax Number:
248-423-5195
Provider Enumeration Date:
11/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BURKE
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-423-5111

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  634550 , 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: 135598503 . This is a "U.S. DEPARTMENT OF LABOR" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 027879 . This is a "MIDWEST HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 09560 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 602897979 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 289797960 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6330390 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1031384 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 34692 . This is a "HEALTH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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