1699934554 NPI number — MICHIGAN INFECTIOUS DISEASE CONSULTANTS PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699934554 NPI number — MICHIGAN INFECTIOUS DISEASE CONSULTANTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN INFECTIOUS DISEASE CONSULTANTS PC
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:
1699934554
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4920 ADAMS POINTE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48098-4111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-212-0678
Provider Business Mailing Address Fax Number:
248-212-0790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44200 WOODWARD AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PONTIAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48341-5046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-212-0678
Provider Business Practice Location Address Fax Number:
248-212-0790
Provider Enumeration Date:
06/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KALYAN
Authorized Official First Name:
SHAMLA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-212-0678

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: 440F306450 . This is a "BCS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1106366471 . This is a "BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1106366471 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4717980 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1699934554 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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