1518087204 NPI number — VALERIE BASKERVILLE DPM

Table of content: VALERIE BASKERVILLE DPM (NPI 1518087204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518087204 NPI number — VALERIE BASKERVILLE DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASKERVILLE
Provider First Name:
VALERIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1518087204
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21650 W 11 MILE RD
Provider Second Line Business Mailing Address:
STE 202
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48076-3777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-792-5200
Provider Business Mailing Address Fax Number:
248-712-4214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3310 W BIG BEAVER RD
Provider Second Line Business Practice Location Address:
SUITE 137
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48084-2809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-792-5200
Provider Business Practice Location Address Fax Number:
248-712-4214
Provider Enumeration Date:
03/29/2007

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: 213EP1101X , with the licence number:  5901001685 , 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: 0H21400 . This is a "BCBSM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3217423 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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