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 | 204F00000X | Transplant Surgery | | | | No |
| 2 | 207K00000X | Allergy & Immunology | | | | No |
| 3 | 207L00000X | Anesthesiology | | | | No |
| 4 | 207N00000X | Dermatology | | | | No |
| 5 | 207P00000X | Emergency Medicine | | | | No |
| 6 | 207Q00000X | Family Medicine | | | | No |
| 7 | 207SG0201X | Medical Genetics | Clinical Genetics (M.D.) | | | No |
| 8 | 207T00000X | Neurological Surgery | | | | No |
| 9 | 207V00000X | Obstetrics & Gynecology | | | | No |
| 10 | 207W00000X | Ophthalmology | | | | No |
| 11 | 207X00000X | Orthopaedic Surgery | | | | No |
| 12 | 207Y00000X | Otolaryngology | | | | No |
| 13 | 207ZP0102X | Pathology | Anatomic Pathology & Clinical Pathology | | | No |
| 14 | 208000000X | Pediatrics | | | | No |
| 15 | 207R00000X | Internal Medicine | | | | 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 | 23D0685178 | OTHER | MICHIGAN | CLIA COMPLIANCE DERM |
| 2 | 23D0913773 | OTHER | MICHIGAN | CLIA - MICROSCOPY OBGYN |
| 3 | 23D1080033 | OTHER | MICHIGAN | CLIA - MICROSCOPY FAM MED |
| 4 | 23D1086626 | OTHER | MICHIGAN | CLIA - WAIVER OTO |
| 5 | 23D1091632 | OTHER | MICHIGAN | CLIA WAIVER |
| 6 | 23D1096986 | OTHER | MICHIGAN | CLIA MICROSCOPY |
| 7 | 23D0701622 | OTHER | MICHIGAN | CLIA - PPM (MODERATE COMPLEXITY) |
| 8 | 23D1040688 | OTHER | MICHIGAN | CLIA - MICROSCOPY UROLOGY |
| 9 | 23D2054540 | OTHER | MICHIGAN | CLIA REGISTRATION (HIGH COMPLEXITY) |
| 10 | 0P30630 | OTHER | MICHIGAN | MEDICARE GROUP # |
| 11 | 23D1019738 | OTHER | MICHIGAN | CLIA - MICROSCOPY INT MED |
| 12 | 0P32120 | OTHER | MICHIGAN | MEDICARE GROUP # - MD/DO FEE LOCALITY 99 |
| 13 | 23D0650703 | OTHER | MICHIGAN | CLIA COMPLIANCE DERM |
| 14 | 0H22832 | OTHER | MICHIGAN | BCBSM GROUP NUMBER |
| 15 | 23D0701623 | OTHER | MICHIGAN | CLIA - MICROSCOPY INT MED |
| 16 | 23D1065430 | OTHER | MICHIGAN | CLIA - WAIVER OTO |
| 17 | 23D2028433 | OTHER | MICHIGAN | CLIA - MICROSCOPY FAM MED |
