Basic Information
| Provider Information | |||||||||
| NPI: | 1659695336 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BI COUNTY MEDICAL PRACTICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HENRY FORD MACOMB HOSPITAL WARREN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 673195 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482673195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107205715 | ||||||||
| FaxNumber: | 8107320891 | ||||||||
| Practice Location | |||||||||
| Address1: | 13355 E 10 MILE RD | ||||||||
| Address2: | SUITE 229 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480892048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867597510 | ||||||||
| FaxNumber: | 5867597791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2010 | ||||||||
| LastUpdateDate: | 06/17/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOODBALIAN | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5862632705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 700E000820 | 01 | MI | BCBSM/BCN | OTHER |