Provider Demographics
NPI:1194807693
Name:MICHIGAN INSTITUTE OF UROLOGY PC
Entity type:Organization
Organization Name:MICHIGAN INSTITUTE OF UROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:DILORETO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-771-4820
Mailing Address - Street 1:20952 12 MILE ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST. CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3203
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:6900 ORCHARD LAKE ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3424
Practice Address - Country:US
Practice Address - Phone:248-539-9036
Practice Address - Fax:248-539-9267
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHIGAN INSTITUTE OF UROLOGY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-20
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540E016120OtherBCBSM DME
MICB9133OtherRAILROAD MEDICARE
MI340E062730OtherBCBSM
MI0E06273Medicare PIN
MI540E016120OtherBCBSM DME