1871558569 NPI number — MARKO R GUDZIAK M.D.

Table of content: MARKO R GUDZIAK M.D. (NPI 1871558569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871558569 NPI number — MARKO R GUDZIAK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUDZIAK
Provider First Name:
MARKO
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1871558569
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20952 E 12 MILE RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
ST CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48081-3200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-771-4820
Provider Business Mailing Address Fax Number:
586-771-6620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44200 WOODWARD
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
PONTIAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48341-2981
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-322-6103
Provider Business Practice Location Address Fax Number:
248-322-6108
Provider Enumeration Date:
04/18/2006

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: 208800000X , with the licence number:  4301063869 , 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: 5205588 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 126142 . This is a "PRIORITY HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0991683 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: F60397 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 340017337 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0605710001 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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