1598842908 NPI number — SALLY BLOCH PHD

Table of content: SALLY BLOCH PHD (NPI 1598842908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598842908 NPI number — SALLY BLOCH PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOCH
Provider First Name:
SALLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1598842908
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2257
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTERTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46304-0357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-926-8320
Provider Business Mailing Address Fax Number:
219-926-3524

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4190 TELEGRAPH RD STE 2700
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMFIELD HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48302-2042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-343-3318
Provider Business Practice Location Address Fax Number:
248-522-7365
Provider Enumeration Date:
11/01/2006

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: 103T00000X , with the licence number:  6301006311 , 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: 680F327530 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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