1619034071 NPI number — SOUTHGATE MEDICAL GROUP, PLLC

Table of content: (NPI 1619034071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619034071 NPI number — SOUTHGATE MEDICAL GROUP, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHGATE MEDICAL GROUP, 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:
6
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:
1619034071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 HERITAGE CENTER
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
SOUTHGATE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-283-3222
Provider Business Mailing Address Fax Number:
734-283-4006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 HERITAGE CENTER
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
SOUTHGATE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-283-3222
Provider Business Practice Location Address Fax Number:
734-283-4006
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NESHEWAT
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
JAMIL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
734-283-3222

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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