1821135831 NPI number — MILTON J GROSENBACH EDD, PC

Table of content: (NPI 1821135831)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821135831 NPI number — MILTON J GROSENBACH EDD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILTON J GROSENBACH EDD, 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:
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:
1821135831
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3562 S LAPEER RD
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
METAMORA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48455-8998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-678-8898
Provider Business Mailing Address Fax Number:
810-678-8808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3562 S LAPEER RD
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
METAMORA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48455-8998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-678-8898
Provider Business Practice Location Address Fax Number:
810-678-8808
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GROSENBACH
Authorized Official First Name:
MILTON
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
DR OWNER
Authorized Official Telephone Number:
810-678-8898

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  6301003782 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 302F00000X , with the licence number: 4101005216 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0M43200 . This is a "MEDICARE ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: OD41119 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0D41076 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 620G44601 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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