Basic Information
Provider Information | |||||||||
NPI: | 1013998731 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WELSH | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26901 BEAUMONT BLVD STE 3D | ||||||||
Address2: |   | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480333849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9475221862 | ||||||||
FaxNumber: | 9475220307 | ||||||||
Practice Location | |||||||||
Address1: | 3577 W 13 MILE RD STE 301 | ||||||||
Address2: |   | ||||||||
City: | ROYAL OAK | ||||||||
State: | MI | ||||||||
PostalCode: | 480736710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2485510669 | ||||||||
FaxNumber: | 2485510058 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/09/2005 | ||||||||
LastUpdateDate: | 10/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 4301405374 | MI | Y |   | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
ID Information
ID | Type | State | Issuer | Description | 294552010 | 05 | MI |   | MEDICAID | 103360635 | 05 | MI |   | MEDICAID | 330F373770 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |