1639121841 NPI number — MANISH N KESLIKER M.D.

Table of content: MANISH N KESLIKER M.D. (NPI 1639121841)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639121841 NPI number — MANISH N KESLIKER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KESLIKER
Provider First Name:
MANISH
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1639121841
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28411 NORTHWESTERN HWY
Provider Second Line Business Mailing Address:
STE # 1050
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48034-0047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-354-4709
Provider Business Mailing Address Fax Number:
248-354-4807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27211 LAHSER ROAD
Provider Second Line Business Practice Location Address:
STE #200
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48034-4147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-358-4892
Provider Business Practice Location Address Fax Number:
248-358-5125
Provider Enumeration Date:
05/16/2006

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: 207R00000X , with the licence number:  MK080609 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 4301080609 , 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: 1346398971 . This is a "CORPORTATE NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104854219 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11-0F33636-0 . This is a "BCBSM GRP PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 20-5485614 . This is a "TAX ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: MK080609 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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