Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | PS007285 | MI |
NPI | 1114134483 |
---|---|
Provider Name | Dr. Paul Robert Stiles |
First Address | Novi, MI 48375-1737 |
Second Address | Novi, MI 48375-1737 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 01/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
950F35409 | BLUE CROSS BLUE SHIELD (01) | MI |