Basic Information
Provider Information | |||||||||
NPI: | 1881633022 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SINAI HOSPITAL OF GREATER DETROIT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SINAI GRACE PHYSICIANS ASSISTANTS GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6071 W OUTER DR | ||||||||
Address2: | SINAI GRACE PHYSICIANS ASSISTANT GROUP | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482352624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3139663300 | ||||||||
FaxNumber: | 8107658169 | ||||||||
Practice Location | |||||||||
Address1: | 6071 W OUTER DR | ||||||||
Address2: | SINAI GRACE PHYSICIANS ASSISTANT GROUP | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482352624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3139663300 | ||||||||
FaxNumber: | 8107658169 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STAVALE | ||||||||
AuthorizedOfficialFirstName: | RONALD | ||||||||
AuthorizedOfficialMiddleName: | XAVIER | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3134404479 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PAC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X |   |   | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X |   |   | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X |   |   | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.