1598900904 NPI number — MACOMB INFECTIOUS DISEASE SPECIALISTS PLLC

Table of content: (NPI 1598900904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598900904 NPI number — MACOMB INFECTIOUS DISEASE SPECIALISTS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MACOMB INFECTIOUS DISEASE SPECIALISTS 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:
1598900904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
46661 FIELDS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBY TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48315-5135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-932-6331
Provider Business Mailing Address Fax Number:
586-797-9111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43134 DEQUINDRE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STERLING HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48314-1723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-446-8688
Provider Business Practice Location Address Fax Number:
586-446-9994
Provider Enumeration Date:
12/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
REDONDO
Authorized Official First Name:
VICENTE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
586-932-6331

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110E027660 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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