Provider Demographics
NPI:1598904237
Name:MICHIGAN INSTITUTE OF UROLOGY, PC
Entity Type:Organization
Organization Name:MICHIGAN INSTITUTE OF UROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALPHONSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SANTINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-771-4820
Mailing Address - Street 1:20952 E 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3200
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:17405 HALL RD
Practice Address - Street 2:STE B
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-4061
Practice Address - Country:US
Practice Address - Phone:586-228-0150
Practice Address - Fax:586-228-0154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0425310003Medicare NSC