1417960139 NPI number — S.E. MICHIGAN DIAGNOSTIC CENTER PC

Table of content: (NPI 1417960139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417960139 NPI number — S.E. MICHIGAN DIAGNOSTIC CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
S.E. MICHIGAN DIAGNOSTIC CENTER 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:
1417960139
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31800 NORTHWESTERN HWY
Provider Second Line Business Mailing Address:
SUITE 370
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48334-1655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-626-0766
Provider Business Mailing Address Fax Number:
248-626-7498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 E 12 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48071-2531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-545-3754
Provider Business Practice Location Address Fax Number:
248-399-6136
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FELDMAN
Authorized Official First Name:
ERWIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
248-399-3550

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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