MEDICARE: REGENTS OF THE UNIVERSITY OF MICHIGAN

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	2084N0600X	Clinical Neurophysiology Physician	MI
2	2084P0005X	Neurodevelopmental Disabilities Physician
3	2084P2900X	Pain Medicine (Psychiatry & Neurology) Physician
4	2084S0010X	Sports Medicine (Psychiatry & Neurology) Physician
5	2084V0102X	Vascular Neurology Physician
6	103G00000X	Clinical Neuropsychologist
7	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician
8	2084B0040X	Behavioral Neurology & Neuropsychiatry Physician
9	2084F0202X	Forensic Psychiatry Physician
10	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician
11	2084N0400X	Neurology Physician

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	130H176260	OTHER	MI	BCBS

NPI Number	:	1053343004
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGENTS OF THE UNIVERSITY OF MICHIGAN

Provider Business Mailing Address
First Line	:	3621 S STATE ST
Second Line	:	PROVIDER ENROLLMENT
City	:	ANN ARBOR
State	:	MI
Zip	:	48108
Country	:	US
Telephone Number	:	734-647-5299
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 E MEDICAL CENTER DR
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48109-5000
Country	:	US
Telephone Number	:	734-936-4000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVID CHRISTOPHER MILLER
Credential	:
Telephone Number	:	734-936-3568

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	05/03/2021