1417916602 NPI number — LORI BUBASH

Table of content: LORI BUBASH (NPI 1417916602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417916602 NPI number — LORI BUBASH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUBASH
Provider First Name:
LORI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1417916602
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26901 BEAUMONT BLVD STE 3D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48033-3849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
947-522-1865
Provider Business Mailing Address Fax Number:
947-522-0307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3601 W 13 MILE RD
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:
48073-6712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-898-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2006

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: 2085R0202X , with the licence number:  4301080761 , 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: 4771321 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300F362420 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".