Basic Information
Provider Information | |||||||||
NPI: | 1104044783 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHFIELD OBSTETRICAL SERVICES PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 30400 TELEGRAPH RD | ||||||||
Address2: | SUITE 350 | ||||||||
City: | BINGHAM FARMS | ||||||||
State: | MI | ||||||||
PostalCode: | 480255814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483539460 | ||||||||
FaxNumber: | 2483538084 | ||||||||
Practice Location | |||||||||
Address1: | 30400 TELEGRAPH RD | ||||||||
Address2: | SUITE 350 | ||||||||
City: | BINGHAM FARMS | ||||||||
State: | MI | ||||||||
PostalCode: | 480255814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483539460 | ||||||||
FaxNumber: | 2483538084 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2007 | ||||||||
LastUpdateDate: | 09/22/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOCHMAN | ||||||||
AuthorizedOfficialFirstName: | LEON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2483539460 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VH0002X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Hospice and Palliative Medicine |
ID Information
ID | Type | State | Issuer | Description | 0F376930 | 01 | MI | MEDICARE PLUS BLUE | OTHER | 1329663 | 05 | MI |   | MEDICAID | 1790780864 | 01 | MI | BLUE CARE NETWORK | OTHER | 160F376930 | 01 | MI | BCBS OF MI FEDERAL EMPLOY | OTHER | 4461641 | 05 | MI |   | MEDICAID | 160F376930 | 01 | MI | BCBS OF MICHIGAN | OTHER | 4461632 | 05 | MI |   | MEDICAID | 4620480 | 05 | MI |   | MEDICAID | 160F376930 | 01 | MI | BLUE CARE NETWORK | OTHER | 9041407 | 05 | MI |   | MEDICAID |