1477634095 NPI number — MICHIGAN COMPREHENSIVE FERTILITY CENTER PLLC

Table of content: SHANE W. COUGHLIN MD (NPI 1336441419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477634095 NPI number — MICHIGAN COMPREHENSIVE FERTILITY CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN COMPREHENSIVE FERTILITY CENTER 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:
1477634095
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 673739
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:
48267-3739
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-299-6650
Provider Business Mailing Address Fax Number:
313-299-6651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18181 OAKWOOD BLVD
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48124-5032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-299-6650
Provider Business Practice Location Address Fax Number:
313-299-6651
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAGYAR
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR,OWNER
Authorized Official Telephone Number:
313-299-6650

Provider Taxonomy Codes

  • Taxonomy code: 207VE0102X , with the licence number:  DM007496 , 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: 160H229510 . This is a "BCBCM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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