Basic Information
Provider Information | |||||||||
NPI: | 1487610481 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALBERTSON | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | DURFFEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | III | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 900 E MICHIGAN AVE | ||||||||
Address2: | STE 105 | ||||||||
City: | JACKSON | ||||||||
State: | MI | ||||||||
PostalCode: | 492012490 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5177823190 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 900 E MICHIGAN AVE | ||||||||
Address2: | STE 105 | ||||||||
City: | JACKSON | ||||||||
State: | MI | ||||||||
PostalCode: | 492012490 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5177823190 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2006 | ||||||||
LastUpdateDate: | 06/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 4301046296 | MI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X | 4301046296 | MI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | 4301046296 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 290007970 | 01 | MI | RR MEDICARE | OTHER | 103112682 | 05 | MI |   | MEDICAID |