Provider Demographics
NPI:1043484421
Name:ROBERT M SODERSTROM MD PC
Entity Type:Organization
Organization Name:ROBERT M SODERSTROM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:SODERSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-733-2090
Mailing Address - Street 1:G5131 W BRISTOL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507
Mailing Address - Country:US
Mailing Address - Phone:810-733-2090
Mailing Address - Fax:810-733-0387
Practice Address - Street 1:G5131 W BRISTOL RD
Practice Address - Street 2:SUITE A
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507
Practice Address - Country:US
Practice Address - Phone:810-733-2090
Practice Address - Fax:810-733-0387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRS032434207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB46958Medicare UPIN
791072165Medicare PIN
MI0257159Medicare PIN