Provider Demographics
NPI:1962674499
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:
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 1:130 TOWN CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-1744
Practice Address - Country:US
Practice Address - Phone:248-786-0464
Practice Address - Fax:248-786-0674
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHIGAN INSTITUTE OF UROLOGY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-25
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208800000X, 2088P0231X, 363L00000X
MI4301090214332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI340E062730OtherBCBSM
MI540E016120OtherBCBSM DME
MICB9133OtherRAILROAD MEDICARE
MI340E062730OtherBCBSM