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 | 207L00000X | Anesthesiology | | 4301059094 | 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 | M001301 | OTHER | | TRICARE REGION 2 & 5 |
| 2 | 30946 | OTHER | | COMMUNITY CHOICE OF M1M |
| 3 | F28381 | MEDICARE UPIN | | |
| 4 | VK059094 | OTHER | | STATE LICENSE NUMBER |
| 5 | 0996930 | OTHER | | HEALTH PLUS OF MICHIGAN |
| 6 | 02582658052 | MEDICARE ID-TYPE UNSPECIFIED | MICHIGAN | |
| 7 | 0B56043018 | OTHER | | PERSONAL IDENTIFICATION |
| 8 | 4647093 | OTHER | | AETNA HEALTH CARE |
| 9 | AN250004 | OTHER | | MCARE INC |
| 10 | 104146 | OTHER | | GREAT LAKES HEALTH PLAN |
| 11 | 223550 | OTHER | | MCLAREN HEALTH PLAN |
| 12 | 0B56043 | MEDICARE ID-TYPE UNSPECIFIED | | |
| 13 | 050B560430 | OTHER | | BLUE CARE NETWORK |
| 14 | EM033063 | OTHER | | HEALTH ALLIANCE PLAN |
| 15 | 223550 | OTHER | | MCLAREN HEALTH ADVANTAGE |
| 16 | 2846890 | MEDICAID | MICHIGAN | |
| 17 | 050B560430 | OTHER | | BLUE CROSS BLUE SHIELD |
| 18 | 1172870001 | OTHER | | THE WELLNESS PLAN |
| 19 | 567566 | OTHER | | SELECT CARE |