Basic Information
Provider Information | |||||||||
NPI: | 1093107682 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MICHIGAN HEALTHCARE PROFESSIONALS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SLEEP DISORDER CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 29992 NORTHWESTERN HWY | ||||||||
Address2: | SUITE C | ||||||||
City: | FARMINGTON HILLS | ||||||||
State: | MI | ||||||||
PostalCode: | 483343292 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2488511430 | ||||||||
FaxNumber: | 2488515182 | ||||||||
Practice Location | |||||||||
Address1: | 29245 RYAN RD | ||||||||
Address2: | SUITE 400 | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480924284 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5865760106 | ||||||||
FaxNumber: | 5865760235 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2015 | ||||||||
LastUpdateDate: | 02/19/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOGOLIN | ||||||||
AuthorizedOfficialFirstName: | MICHAELENE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ASS SECRETARY OF CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 2488511430 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
No ID Information.