Basic Information
| Provider Information | |||||||||
| NPI: | 1093919532 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHN N DI BELLA MDPC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1451 CEDARWOOD DR | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484331875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106597592 | ||||||||
| FaxNumber: | 8106597202 | ||||||||
| Practice Location | |||||||||
| Address1: | 335 E HOUGHTON AVE | ||||||||
| Address2: | |||||||||
| City: | WEST BRANCH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486611127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893433124 | ||||||||
| FaxNumber: | 9893433165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 01/30/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DI BELLA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8106597592 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 4301062732 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0506500432 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 0506500432 | 01 | MI | BLUE CARE NETWORK HMO | OTHER | 411742210 | 05 | MI | MEDICAID |