Provider Demographics
NPI:1184881971
Name:ALFONSO ACOSTA MD PC
Entity type:Organization
Organization Name:ALFONSO ACOSTA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-929-0842
Mailing Address - Street 1:PO BOX 250433
Mailing Address - Street 2:
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48325-0433
Mailing Address - Country:US
Mailing Address - Phone:586-929-0842
Mailing Address - Fax:248-366-0065
Practice Address - Street 1:7173 ILANAWAY DR
Practice Address - Street 2:
Practice Address - City:W BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48324-2493
Practice Address - Country:US
Practice Address - Phone:586-929-0842
Practice Address - Fax:248-366-0065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064369208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00193884OtherRAILROAD MEDICARE
MI103522994Medicaid
1106335602OtherBCBSM
1106335602OtherBCBSM
P00193884OtherRAILROAD MEDICARE