1225209893 NPI number — JS DUDOVITZ, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225209893 NPI number — JS DUDOVITZ, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JS DUDOVITZ, INC
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:
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:
1225209893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6650 HIGHLAND RD
Provider Second Line Business Mailing Address:
118
Provider Business Mailing Address City Name:
WATERFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48327-1660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-666-3377
Provider Business Mailing Address Fax Number:
248-666-4332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6650 HIGHLAND RD
Provider Second Line Business Practice Location Address:
118
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48327-1660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-666-3377
Provider Business Practice Location Address Fax Number:
248-666-4332
Provider Enumeration Date:
03/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DUDOVITZ
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-666-3377

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 900F33410 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".




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