Provider Demographics
NPI:1114958899
Name:LI, CHANGXIN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANGXIN
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 N CENTER AVE
Mailing Address - Street 2:SUITE 298
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1595
Mailing Address - Country:US
Mailing Address - Phone:989-731-7708
Mailing Address - Fax:989-731-7929
Practice Address - Street 1:829 N CENTER AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1595
Practice Address - Country:US
Practice Address - Phone:989-731-7870
Practice Address - Fax:989-731-7837
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058124207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC6209OtherMEDICARE RR PROV ID
MI1106900352OtherBCBSM PROVIDER NUMBER
11281960OtherCAQH PROVIDER ID
381303843OtherTAX ID
MI4299165Medicaid
0F96004005Medicare ID - Type UnspecifiedPROVIDER NUMBER
G05612Medicare UPIN