1811171234 NPI number — CHRISTOPHER R DEANGELIS D.O

Table of content: MR. SIK KIYOSHI KIM MD (NPI 1891757043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811171234 NPI number — CHRISTOPHER R DEANGELIS D.O

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRISTOPHER R DEANGELIS D.O
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:
1811171234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25000 HALL RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
WOODHAVEN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48183-5112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-676-3373
Provider Business Mailing Address Fax Number:
734-675-1678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25000 HALL RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
WOODHAVEN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48183-5112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-676-3373
Provider Business Practice Location Address Fax Number:
734-675-1678
Provider Enumeration Date:
12/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REIMAN
Authorized Official First Name:
SARA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
734-676-3373

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  CD013396 , 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: 5390707 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P127746 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1158206834 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5820683 . This is a "BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C8111 . This is a "M CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110218318 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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