=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124213921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BI COUNTY CLINICAL PRACTICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2007
-----------------------------------------------------
Last Update Date | 10/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27500 HOOVER RD STE 100
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093-4586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-754-2558
-----------------------------------------------------
Fax | 586-754-2426
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 673195
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48267-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-720-5715
-----------------------------------------------------
Fax | 810-732-0891
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | JOHN KIBBLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-874-3436
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------