1396812624 NPI number — GROSSE PTE OBSTETRICS & GYN PC

Table of content: (NPI 1396812624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396812624 NPI number — GROSSE PTE OBSTETRICS & GYN PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GROSSE PTE OBSTETRICS & GYN 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:
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:
1396812624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25910 KELLY RD
Provider Second Line Business Mailing Address:
STE 9
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48066-4466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-779-6222
Provider Business Mailing Address Fax Number:
586-779-6228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25910 KELLY RD
Provider Second Line Business Practice Location Address:
STE 9
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48066-4466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-779-6222
Provider Business Practice Location Address Fax Number:
586-779-6228
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ZAJDEL
Authorized Official First Name:
GRAZYNA
Authorized Official Middle Name:
KRYSTINA
Authorized Official Title or Position:
CORPORATION PRESIDENT
Authorized Official Telephone Number:
313-882-6780

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  GZ051612 , 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: 3383620 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: GZ051612 . This is a "MI STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: A78218 . This is a "HAP PROVIDER NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0360747 . This is a "ACOG NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1608250512 . This is a "BCBS NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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