1043535990 NPI number — BI COUNTY CLINICAL PRACTICES

Table of content: (NPI 1043535990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043535990 NPI number — BI COUNTY CLINICAL PRACTICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BI COUNTY CLINICAL PRACTICES
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:
1043535990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 673195
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48267-3195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-720-5715
Provider Business Mailing Address Fax Number:
810-732-0891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27500 HOOVER RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48093-4586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-754-2558
Provider Business Practice Location Address Fax Number:
586-754-2426
Provider Enumeration Date:
04/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GOODBALIAN
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
586-263-2705

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , 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: 700E002070 . This is a "BCBSM/BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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