Basic Information
| Provider Information | |||||||||
| NPI: | 1073708772 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BI-COUNTY CLINICAL PRACTICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 673937 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482670001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867586263 | ||||||||
| FaxNumber: | 5867587725 | ||||||||
| Practice Location | |||||||||
| Address1: | 13355 E 10 MILE RD | ||||||||
| Address2: | SUITE 229 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480892048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867556263 | ||||||||
| FaxNumber: | 5867587725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | KIBBLE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3138743436 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 770E002070 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |