Basic Information
Provider Information | |||||||||
NPI: | 1609804939 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LUM | ||||||||
FirstName: | LEIGHTON | ||||||||
MiddleName: | MS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 32627 | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482320627 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8667441452 | ||||||||
FaxNumber: | 5864124101 | ||||||||
Practice Location | |||||||||
Address1: | 1375 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LAPEER | ||||||||
State: | MI | ||||||||
PostalCode: | 484461350 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8106675500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2006 | ||||||||
LastUpdateDate: | 02/06/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5101004913 | MI | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 300049507 | 01 | MI | RRMC | OTHER | 1917511 | 05 | MI |   | MEDICAID | 310D460020 | 01 | MI | BCBS GROUP PIN # | OTHER | 300F361250 | 01 | MI | BCBS GROUP # | OTHER | CA3518 | 01 | MI | MEDICARE RR GROUP PIN | OTHER | 1915992 | 05 | MI |   | MEDICAID | 3156301714 | 01 | MI | BCBS INDIVIDUAL PIN # | OTHER |