Basic Information
| Provider Information | |||||||||
| NPI: | 1740210608 | ||||||||
| 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: | 1500 E MEDICAL CENTER DR | ||||||||
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| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349364000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| 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: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207SC0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Cytogenetic | 207SG0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Biochemical Genetics | 207SG0203X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Molecular Genetics | 207SG0205X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Ph.D. Medical Genetics | 207SM0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Molecular Genetic Pathology | 207SG0201X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) |
ID Information
| ID | Type | State | Issuer | Description | 110H111640 | 01 | MI | BCBS | OTHER |