Provider Demographics
NPI:1598900904
Name:MACOMB INFECTIOUS DISEASE SPECIALISTS PLLC
Entity Type:Organization
Organization Name:MACOMB INFECTIOUS DISEASE SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICENTE
Authorized Official - Middle Name:
Authorized Official - Last Name:REDONDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-932-6331
Mailing Address - Street 1:46661 FIELDS DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-5135
Mailing Address - Country:US
Mailing Address - Phone:586-932-6331
Mailing Address - Fax:586-797-9111
Practice Address - Street 1:43134 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1723
Practice Address - Country:US
Practice Address - Phone:586-446-8688
Practice Address - Fax:586-446-9994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-14
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110E027660OtherBLUE CROSS BLUE SHIELD OF MICHIGAN