1730393927 NPI number — MICHIGAN INSTITUTE OF UROLOGY 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 1730393927 NPI number — MICHIGAN INSTITUTE OF UROLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN INSTITUTE OF UROLOGY 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:
1730393927
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20952 12 MILE ROAD
Provider Second Line Business Mailing Address:
200
Provider Business Mailing Address City Name:
SAINT CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48081-3203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-771-4820
Provider Business Mailing Address Fax Number:
586-771-9616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20952 12 MILE ROAD
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
SAINT CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48081-3203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-771-4820
Provider Business Practice Location Address Fax Number:
586-771-9616
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SANTINO
Authorized Official First Name:
ALPHONSE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
586-771-4820

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CB9133 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 340E062730 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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