Provider Demographics
NPI:1801081450
Name:CHARLOTTE LIIOI HARTZELL, M.D., P.C.
Entity type:Organization
Organization Name:CHARLOTTE LIIOI HARTZELL, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIIOI HARTZELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-884-2009
Mailing Address - Street 1:515 HEATHER LN
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1509
Mailing Address - Country:US
Mailing Address - Phone:313-884-2009
Mailing Address - Fax:
Practice Address - Street 1:2877 CROOKS RD
Practice Address - Street 2:SUITE B
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4717
Practice Address - Country:US
Practice Address - Phone:313-318-8205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052708207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1806361411OtherBCBSM OF MICIGAN
MI0N40420Medicare PIN