Basic Information
| Provider Information | |||||||||
| NPI: | 1437577061 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACTIVATE HEALTHCARE MICHIGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2115 N DAMEN AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606474528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736973144 | ||||||||
| FaxNumber: | 7736971437 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 HORACE BROWN DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480711867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736973144 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2014 | ||||||||
| LastUpdateDate: | 04/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | GEIHSLER | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRINCIPAL | ||||||||
| AuthorizedOfficialTelephone: | 7736973144 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | APPLYING FOR | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | APPLYING FOR | 01 | MI | MEDICARE PTAN | OTHER |