Basic Information
Provider Information | |||||||||
NPI: | 1679293757 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DETROIT ORTHOPEDICS & SPORTS MEDICINE PLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 145 | ||||||||
Address2: |   | ||||||||
City: | NOVI | ||||||||
State: | MI | ||||||||
PostalCode: | 483760145 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3133196858 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 27207 LAHSER RD STE 250 | ||||||||
Address2: |   | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480342168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2485958518 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2022 | ||||||||
LastUpdateDate: | 08/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NZOMA | ||||||||
AuthorizedOfficialFirstName: | JONATHAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3133196858 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.