1790715480 NPI number — YEHIA I ELSAFY M D P L C

Table of content: (NPI 1790715480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790715480 NPI number — YEHIA I ELSAFY M D P L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YEHIA I ELSAFY M D P L C
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:
1790715480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4296 GRATIOT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT HURON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48060-1599
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-985-6680
Provider Business Mailing Address Fax Number:
810-985-6809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2425 MILITARY ST
Provider Second Line Business Practice Location Address:
BUILDING #1
Provider Business Practice Location Address City Name:
PORT HURON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48060-6692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-985-6680
Provider Business Practice Location Address Fax Number:
810-985-6809
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ELSAFY
Authorized Official First Name:
YEHIA
Authorized Official Middle Name:
IBRAHAM
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
810-985-6680

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4301045260 , 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: 110741052 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4712788 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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