Basic Information
| Provider Information | |||||||||
| NPI: | 1013935733 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENTS OF THE UNIVERSITY OF MICHIGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346475299 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8001 CHALLIS ROAD | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102279510 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7349363568 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0008X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 2080S0010X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine | 2080T0002X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Medical Toxicology | 208M00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 2080A0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2080I0007X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Clinical & Laboratory Immunology | 208000000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 350D711420 | 01 | MI | BCBS | OTHER |