Healthcare Provider Details

I. General information

NPI: 1033524335
Provider Name (Legal Business Name): REGENTS OF THE UNIVERSITY OF MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 04/30/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 FRANK LLOYD WRIGHT DR
ANN ARBOR MI
48105-9484
US

IV. Provider business mailing address

3621 S STATE ST PROVIDER ENROLLMENT
ANN ARBOR MI
48108
US

V. Phone/Fax

Practice location:
  • Phone: 734-930-7400
  • Fax:
Mailing address:
  • Phone: 734-647-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code2084S0010X
TaxonomySports Medicine (Psychiatry & Neurology) Physician
License Number
License Number StateMI
# 8
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: DAVID CHRISTOPHER MILLER
Title or Position: PRESIDENT
Credential:
Phone: 734-936-3568