1437334257 NPI number — SOUTHEAST MICHIGAN NEUROSURGERY PLLC

Table of content: (NPI 1437334257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437334257 NPI number — SOUTHEAST MICHIGAN NEUROSURGERY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST MICHIGAN NEUROSURGERY 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:
1437334257
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3535 WEST 13 MILE ROAD
Provider Second Line Business Mailing Address:
SUITE 504
Provider Business Mailing Address City Name:
ROYAL OAK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-551-3020
Provider Business Mailing Address Fax Number:
248-551-3019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 WEST 13 MILE ROAD
Provider Second Line Business Practice Location Address:
SUITE 504
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-551-3020
Provider Business Practice Location Address Fax Number:
248-551-3019
Provider Enumeration Date:
12/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ZAKALIK
Authorized Official First Name:
KAROL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-551-3020

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  4301050230 , 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: 140F344180 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2769781-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: PTAN P00455528 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: DG8023 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: OP52120 . This is a "PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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