Healthcare Provider Details

I. General information

NPI: 1801978309
Provider Name (Legal Business Name): MICHIGAN INSTITUTE OF UROLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 HAGGERTY ROAD SUITE 2000
WEST BLOOMFIELD MI
48323-2102
US

IV. Provider business mailing address

20952 E 12 MILE RD SUITE 200
SAINT CLAIR SHORES MI
48081-3200
US

V. Phone/Fax

Practice location:
  • Phone: 248-624-9900
  • Fax: 248-896-5450
Mailing address:
  • Phone: 586-771-4820
  • Fax: 586-771-6620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: ALPHONSE SANTINO
Title or Position: PRESIDENT
Credential: MD
Phone: 586-771-4820