Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207PE0004X | Emergency Medical Services | LC012791 | MI |
Y | 207Q00000X | Family Doctor | 5101012791 | MI |
NPI | 1164477816 |
---|---|
Provider Name | Mr. Loren Chudler |
First Address | Southfield, MI 48075 |
Second Address | Southfield, MI 48075 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/05/2006 |
Last Update Date | 24/04/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
114351390 | (05) | MI |
G58655 | (02) | |
LC012791 | BCBS (01) | MI |