Basic Information
Provider Information | |||||||||
NPI: | 1245234509 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DELOOF | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MISUKIEWICZ | ||||||||
OtherFirstName: | PATRICIA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1746 MOMENTUM PL | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606895317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5867318400 | ||||||||
FaxNumber: | 5867318406 | ||||||||
Practice Location | |||||||||
Address1: | 50505 SCHOENHERR RD | ||||||||
Address2: | SUITE 340 | ||||||||
City: | SHELBY TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 483153140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5867318400 | ||||||||
FaxNumber: | 5867318406 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2005 | ||||||||
LastUpdateDate: | 08/29/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301055902 | MI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 4301055902 | MI | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 4846360 | 05 | MI |   | MEDICAID | PD055902 | 01 | MI | BCBSM | OTHER |