1891303061 NPI number — PFEFFERKORN MD PLLC

Table of content: (NPI 1891303061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891303061 NPI number — PFEFFERKORN MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PFEFFERKORN MD PLLC
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:
1891303061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6490 BROCKHURST BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
W BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48322-1230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46325 W 12 MILE RD STE 390
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NOVI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48377-2464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-719-7271
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2020

Additional Information

Authorized Official

Authorized Official Last Name:
PFEFFERKORN
Authorized Official First Name:
TASSIA
Authorized Official Middle Name:
ZOMA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-860-8009

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4301100187 . This is a "LARA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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