Provider Demographics
NPI:1598865735
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:AM
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:REGINALDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-771-4820
Mailing Address - Street 1:25 MICHIGAN ST NE STE 3300
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2558
Mailing Address - Country:US
Mailing Address - Phone:616-459-4171
Mailing Address - Fax:616-459-0044
Practice Address - Street 1:25 MICHIGAN ST NE
Practice Address - Street 2:SUITE 3300
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2515
Practice Address - Country:US
Practice Address - Phone:616-459-4171
Practice Address - Fax:616-459-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208800000X
332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16060OtherBLUE CROSS BLUE SHIEL
MI0D16060OtherBLUE CROSS BLUE SHIEL