1770575706 NPI number — AMERICAN DIABETIC SUPPLY, INC.

Table of content: DAVID MARC VIRSHUP M.D. (NPI 1962581538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770575706 NPI number — AMERICAN DIABETIC SUPPLY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMERICAN DIABETIC SUPPLY, INC.
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:
1770575706
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 602
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOVI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48376-0602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-449-8055
Provider Business Mailing Address Fax Number:
888-449-8057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28317 BECK RD
Provider Second Line Business Practice Location Address:
E-18
Provider Business Practice Location Address City Name:
WIXOM
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48393-4729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-449-8055
Provider Business Practice Location Address Fax Number:
888-449-8057
Provider Enumeration Date:
08/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CARLIN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-449-8055

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , 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: 2750287 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 54-0-F3-1442-0 . This is a "BCBSMI PROVIDER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4979367 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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