Provider Demographics
NPI:1164477816
Name:CHUDLER, LOREN (DO)
Entity Type:Individual
Prefix:MR
First Name:LOREN
Middle Name:
Last Name:CHUDLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 TOWN CENTER
Mailing Address - Street 2:SUITE 650
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-430-5350
Mailing Address - Fax:248-352-5211
Practice Address - Street 1:2000 TOWN CENTER
Practice Address - Street 2:SUITE 650
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-352-5851
Practice Address - Fax:248-352-5211
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILC012791207PE0004X
MI5101012791207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MILC012791OtherBCBS
MI114351390Medicaid
MILC012791OtherBCBS
MI114351390Medicaid
MI$$$$$$$$$OtherCHAMPUS
MILC012791OtherBCBS