1891957965 NPI number — FARMINGTON HILLS INTERNAL MEDICINE PC

Table of content: (NPI 1891957965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891957965 NPI number — FARMINGTON HILLS INTERNAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FARMINGTON HILLS INTERNAL MEDICINE PC
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:
FARMINGTON HILLS INTERNAL MEDICINE
Provider Other Organization Name Type Code:
3
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:
1891957965
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26206 W 12 MILE RD
Provider Second Line Business Mailing Address:
SUITE #200
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48034-1754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-827-4322
Provider Business Mailing Address Fax Number:
248-827-7822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26206 W 12 MILE RD
Provider Second Line Business Practice Location Address:
SUITE #200
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48034-1754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-827-4322
Provider Business Practice Location Address Fax Number:
248-827-7822
Provider Enumeration Date:
06/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
AMOS
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
CEO & PRESIDENT
Authorized Official Telephone Number:
248-827-4322

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: 0110634082 . This is a "BCBSM PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0110930751 . This is a "BCBSM NEW INDIVIDUAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104099772 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1891957965 . This is a "GROUP NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0F39878 . This is a "BCBSM GROUP ID#" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1801805270 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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