Basic Information
Provider Information | |||||||||
NPI: | 1093028359 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MACAGBA | ||||||||
FirstName: | GLADYS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 35500 ASHTON CT | ||||||||
Address2: |   | ||||||||
City: | CLINTON TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 480352169 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 17800 KEDZIE AVE | ||||||||
Address2: |   | ||||||||
City: | HAZEL CREST | ||||||||
State: | IL | ||||||||
PostalCode: | 604292029 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3126090300 | ||||||||
FaxNumber: | 7087476830 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2010 | ||||||||
LastUpdateDate: | 12/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5315045564 | MI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 5101018740 | MI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 036-133694 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.