Provider Demographics
NPI:1649200437
Name:KAUFMAN, HERBERT R (DO)
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:R
Last Name:KAUFMAN
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:PO BOX 1108
Mailing Address - Street 2:ATTN: BARB SIMMONS
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-1108
Mailing Address - Country:US
Mailing Address - Phone:734-677-7400
Mailing Address - Fax:734-677-7407
Practice Address - Street 1:399 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-2740
Practice Address - Country:US
Practice Address - Phone:248-338-5604
Practice Address - Fax:734-677-7407
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010050272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICA3518OtherMEDICARE RR GROUP PIN
MI300F361250OtherBCBS GROUP PIN
MI3156309204OtherBCBS PIN #
MI1327210Medicaid
MI3156309204OtherBCBS PIN #
MI300F361250OtherBCBS GROUP PIN
E25973Medicare UPIN
MI0F36125018Medicare PIN