Basic Information
| Provider Information | |||||||||
| NPI: | 1295905743 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MICHIGAN ORTHOPEDIC SURGERY AND REHABILITATION, P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6565 W MAIN ST | ||||||||
| Address2: | SUITE 235 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490096114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695444715 | ||||||||
| FaxNumber: | 2695444719 | ||||||||
| Practice Location | |||||||||
| Address1: | 6565 W MAIN ST | ||||||||
| Address2: | SUITE 235 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490096114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695444715 | ||||||||
| FaxNumber: | 2695444719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2008 | ||||||||
| LastUpdateDate: | 10/24/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PIERMAN | ||||||||
| AuthorizedOfficialFirstName: | PATTI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2693416417 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4301041296 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2003984572 | 01 | MI | BLUE CARE NETWORK | OTHER | 2576506 | 05 | MI | MEDICAID | 2003984572 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 791203295 | 01 | R/R MEDICARE PIN | OTHER |