1851318752 NPI number — DR. GARY CHODOROFF MD

Table of content: DR. GARY CHODOROFF MD (NPI 1851318752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851318752 NPI number — DR. GARY CHODOROFF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHODOROFF
Provider First Name:
GARY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1851318752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30100 TELEGRAPH RD
Provider Second Line Business Mailing Address:
SUITE 177
Provider Business Mailing Address City Name:
BINGHAM FARMS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48025-4514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-647-1470
Provider Business Mailing Address Fax Number:
248-647-1472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30100 TELEGRAPH RD
Provider Second Line Business Practice Location Address:
SUITE 177
Provider Business Practice Location Address City Name:
BINGHAM FARMS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48025-4560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-647-1470
Provider Business Practice Location Address Fax Number:
248-647-1472
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  GC046805 , 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: 49558 . This is a "HAP THRU PROVIDENCE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0633719 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 101420 . This is a "PREFERRED CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4052753 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1106337 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 250F334790 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 101420 . This is a "CARE CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C3352 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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