Provider Demographics
NPI:1972530947
Name:BLUE CARE NETWORK OF MI
Entity type:Organization
Organization Name:BLUE CARE NETWORK OF MI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:LANIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-322-8007
Mailing Address - Street 1:P O BOX 77000
Mailing Address - Street 2:DEPARTMENT 77251
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-0251
Mailing Address - Country:US
Mailing Address - Phone:517-664-4727
Mailing Address - Fax:
Practice Address - Street 1:1525 W LAKE LANSING RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823
Practice Address - Country:US
Practice Address - Phone:517-664-4727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060832207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110C360380OtherBCBS
MI080169243Medicare ID - Type UnspecifiedMEDICARE