Provider Demographics
NPI:1992081640
Name:REGENTS OF THE UNIVERSITY OF MICHIGAN
Entity type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-936-3568
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1200 SIXTH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2369
Practice Address - Country:US
Practice Address - Phone:231-935-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENTS OF THE UNIVERSITY OF MICHIGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-26
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208000000X, 2080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric RheumatologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D76004Medicare PIN