1972678548 NPI number — DR. MICHELLE BONITA CALHOUN D.O.

Table of content: DR. MICHELLE BONITA CALHOUN D.O. (NPI 1972678548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972678548 NPI number — DR. MICHELLE BONITA CALHOUN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALHOUN
Provider First Name:
MICHELLE
Provider Middle Name:
BONITA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CALHOUN
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
BONITA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1972678548
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27207 LAHSER RD
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48034-2168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-967-3200
Provider Business Mailing Address Fax Number:
248-967-1387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27207 LAHSER RD
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48034-2168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-967-3200
Provider Business Practice Location Address Fax Number:
248-967-1387
Provider Enumeration Date:
11/21/2006

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: 207R00000X , with the licence number:  5101012320 , 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: 56310495 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 471738075 . This is a "TAX ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5633229 . This is a "BCBSM PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: OP46640 . This is a "GROUP PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4546506-11 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5101012320 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P46640001 . This is a "PROVIDER PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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