Provider Demographics
NPI:1619025392
Name:SOUTHFIELD LATHRUP OBSTETRICS AND GYNECOLOGY PC
Entity Type:Organization
Organization Name:SOUTHFIELD LATHRUP OBSTETRICS AND GYNECOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ZACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-476-4900
Mailing Address - Street 1:20276 MIDDLEBELT RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2054
Mailing Address - Country:US
Mailing Address - Phone:248-476-4900
Mailing Address - Fax:248-476-5435
Practice Address - Street 1:20276 MIDDLEBELT ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:248-476-4900
Practice Address - Fax:248-476-5435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F37177OtherBCBS
MI0F37177Medicare ID - Type Unspecified