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 | 207RG0100X | Internal Medicine | Gastroenterology | HG060600 | 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 | 261859452 | OTHER | MICHIGAN | TIN 04/25/2008 |
| 2 | 1679538581 | MEDICAID | MICHIGAN | |
| 3 | 100013736 | MEDICARE PIN | MICHIGAN | |
| 4 | 0P56360004 | OTHER | MICHIGAN | MEDICARE 04/25/2008 AND AFTER |
| 5 | 104171768 | MEDICAID | MICHIGAN | |
| 6 | C97618345 BRONSON | MEDICARE PIN | MICHIGAN | |
| 7 | 100987 | OTHER | MICHIGAN | GREAT LAKES HEALTH PLAN |
| 8 | 0M92920001 | OTHER | MICHIGAN | MEDICARE |
| 9 | E18264 | MEDICARE UPIN | MICHIGAN | |
| 10 | 1417961137 | OTHER | MICHIGAN | BCBSM - BRONSON |
| 11 | 4319176 | OTHER | MICHIGAN | AETNA |
| 12 | 100C914640 | OTHER | MICHIGAN | BCBS 04/25/2008 AND AFTER |
| 13 | 1851569958 | OTHER | MICHIGAN | NPI 04/25/2008 AND AFTER |
| 14 | 383309299137 | OTHER | MICHIGAN | CARESOURCE MEDICAID |
| 15 | 100C910690 | OTHER | MICHIGAN | BCBSM |
| 16 | 1679538581 | OTHER | MICHIGAN | NPI |
| 17 | HG060600 | OTHER | MICHIGAN | BLUE CROSS BLUE SHIELD |
