Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 207Q00000X | Family Medicine | | 5101012293 | MICHIGAN | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 0852502204 | OTHER | MICHIGAN | BLUE CROSS BLUE SHIELD |
| 2 | C7899 | OTHER | MICHIGAN | MCARE |
| 3 | 4361486 | MEDICAID | MICHIGAN | |
| 4 | 5639565 | OTHER | MICHIGAN | AETNA |
| 5 | 9921034004 | OTHER | MICHIGAN | CIGNA |
| 6 | G56808 | OTHER | MICHIGAN | HEALTH ALLIANCE PLAN |
| 7 | 080D410020 | OTHER | MICHIGAN | COMMUNITY BLUE |
| 8 | 253396 | OTHER | MICHIGAN | MCLAREN HEALTH PLAN |
| 9 | G56808 | MEDICARE UPIN | MICHIGAN | |
| 10 | G56808 | OTHER | MICHIGAN | HEALTH NET FEDERAL SERV |
| 11 | 080172343 | OTHER | MICHIGAN | METRAHEALTH |
| 12 | 080D410020 | OTHER | MICHIGAN | BLUE CARE NETWORK |
| 13 | 080D410020 | OTHER | MICHIGAN | BLUE CROSS POS |
| 14 | 0M28430 | MEDICARE ID-TYPE UNSPECIFIED | MICHIGAN | |
| 15 | 0M28430110 | MEDICARE ID-TYPE UNSPECIFIED | MICHIGAN | |
| 16 | 080D410020 | OTHER | MICHIGAN | BLUE CROSS BLUE SHIELD |
| 17 | 0990939 | OTHER | MICHIGAN | HEALTH PLUS |
| 18 | 253396 | OTHER | MICHIGAN | HEALTH ADVANTAGE NETWORK |
