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 | 207R00000X | Internal Medicine | | 4301078831 | MICHIGAN | No |
| 2 | 208M00000X | Hospitalist | | 4301078831 | 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 | 382317300 140 | OTHER | MICHIGAN | COMM CHOICE MI-IM |
| 2 | 1107500612 | OTHER | MICHIGAN | BCBS PIN |
| 3 | 382317300 107 | OTHER | MICHIGAN | COMM CHOICE MI-WP |
| 4 | 382317300 154 | OTHER | MICHIGAN | COMM CHOICE MI-TR |
| 5 | 700G560080 | OTHER | MICHIGAN | BCBS GROUP |
| 6 | 0G56008 | OTHER | MICHIGAN | MEDICARE GROUP |
| 7 | 143068 | OTHER | MICHIGAN | GREAT LAKES HEALTH PLAN-T |
| 8 | 4460009 10 | MEDICAID | MICHIGAN | |
| 9 | 4601303 10 | MEDICAID | MICHIGAN | |
| 10 | 4347244 10 | MEDICAID | MICHIGAN | |
| 11 | 4848285 | MEDICAID | MICHIGAN | |
| 12 | 4938130 10 | MEDICAID | MICHIGAN | |
