Basic Information
| Provider Information | |||||||||
| NPI: | 1730135294 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INFECTIOUS DISEASES ASSOCIATES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5333 MCAULEY DR | ||||||||
| Address2: | R3106 | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347128600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5333 MCAULEY DR | ||||||||
| Address2: | R3106 | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347128600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | OTTO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7347128600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | 029166 | MI | Y | Managed Care Organizations | Exclusive Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 1046837 | 05 | MI | MEDICAID |