OAKLAND GASTROENTEROLOGY ASSOCIATES, P.C.
Complete NPI Record 1508964511
Internal Medicine - Gastroenterology in Royal Oak, MI

Active since September 21, 2006CLIA 23D1076937 · Waiver

3535 W 13 MILE RD, SUITE 202, ROYAL OAK, MI 48073(248) 551-0900(248) 551-0905 Get Directions

NPPES record last updated: May 5, 2014. Verified against the NPPES registry weekly; last sync: July 19, 2026.

Complete NPI Dataset

This page contains the complete raw NPPES record for Oakland Gastroenterology Associates, P.c. (NPI 1508964511), an internal medicine organization in Royal Oak, MI. All 74 fields on file are listed with their current values and official NPPES definitions, exactly as recorded in the National Plan and Provider Enumeration System. Only fields that contain data are included, so the number of fields shown varies from one NPI record to another.

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NPI: 1508964511: The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
Entity Type Code: 2: Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Employer Identification Number EIN: Not available: The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
Provider Organization Name Legal Business Name: OAKLAND GASTROENTEROLOGY ASSOCIATES, P.C.: The name of the organization provider. If the provider is an organization, this is the legal business name.
Provider First Line Business Mailing Address: 3535 W 13 MILE RD: The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
Provider Second Line Business Mailing Address: SUITE 202: The second line mailing address of the provider being identified. This data element may contain the same information as "Provider second line location address".
Provider Business Mailing Address City Name: ROYAL OAK: The city name in the mailing address of the provider being identified.
Provider Business Mailing Address State Name: MI: The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
Provider Business Mailing Address Postal Code: 480736770: The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
Provider Business Mailing Address Country Code If outside U S : US: The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
Provider Business Mailing Address Telephone Number: 2485510900: The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
Provider Business Mailing Address Fax Number: 2485510905: The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
Provider First Line Business Practice Location Address: 3535 W 13 MILE RD: The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Second Line Business Practice Location Address: SUITE 202: The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name: ROYAL OAK: The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name: MI: The State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code: 480736770: The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S : US: The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number: 2485510900: The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number: 2485510905: The fax number associated with the location address of the provider being identified.
Provider Enumeration Date: 9/21/2006: The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date: 5/5/2014: The date that a record was last updated or changed.
Authorized Official Last Name: POLIDORI: The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First Name: GREGG: The first name of the authorized official.
Authorized Official Title or Position: PRESIDENT: The title or position of the authorized official.
Authorized Official Telephone Number: 2485510900: The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code 1: 207RG0100X: This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
Provider License Number 1: 4301044285: The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with "provider taxonomy code".
Provider License Number State Code 1: MI: The two-letter state code representing the U.S. state or territory that issued the provider's license. This field is linked to the Provider License Number field and identifies the jurisdiction where that license is valid. A provider may have multiple state codes if they hold licenses in more than one state.
Healthcare Provider Primary Taxonomy Switch 1: Y: This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
Other Provider Identifier 1: 2836211: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 1: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 1: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 2: 100F37143: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 2: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 2: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier Issuer 2: BCBS AND BCN: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 3: 4101048: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 3: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 3: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 4: 4257380: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 4: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 4: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 5: 4340940: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 5: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 5: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 6: 3364901: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 6: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 6: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 7: 4258298: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 7: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 7: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 8: 4592984: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 8: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 8: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 9: 4257370: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 9: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 9: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 10: 2836230: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 10: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 10: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 11: 4310182: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 11: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 11: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 12: 4318636: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 12: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 12: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 13: 4340978: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 13: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 13: MI: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Is Organization Subpart: N: Indicates whether the provider is a subpart of a larger organization. This is a single-character code: "Y" means the entity is an organizational subpart, while "N" means it is not. Subparts typically include hospital departments, clinics, or other distinct units that fall under a parent organization.
Authorized Official Name Prefix Text: DR.: The prefix used in the name of the authorized official associated with the provider's NPI record. Examples include Mr., Ms., Mrs., Dr., or other common professional or personal prefixes.
Authorized Official Credential Text: M.D.: The professional credential(s) of the authorized official listed on the provider's NPI record. Examples include MD (Doctor of Medicine), DO (Doctor of Osteopathy), RN (Registered Nurse), DDS (Doctor of Dental Surgery), PhD, or other recognized designations that reflect the official's qualifications.
Healthcare Provider Taxonomy Group 1: 193400000X SINGLE SPECIALTY GROUP: Specifies whether the provider is part of a single-specialty or multi-specialty business group. The possible values are: 193200000X – Multi-Specialty Group or 193400000X – Single Specialty Group. This field helps distinguish the organizational structure of a provider group.

Other Provider Identifiers 20

Legacy and payer-issued identifiers reported to the NPPES registry for this provider.

F28208 Medicare UPIN

1/20

State: MI
Medicare UPIN (Unique Physician Identification Number): A legacy six-character alphanumeric identifier previously issued by Medicare to individual physicians before being retired and replaced by the NPI system.

E76131 Medicare UPIN

2/20

4340940 Medicaid

3/20

State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

4257370 Medicaid

4/20

State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

G31464 Medicare UPIN

5/20

E76232 Medicare UPIN

6/20

2836230 Medicaid

7/20

State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

4257380 Medicaid

8/20

State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

4340978 Medicaid

9/20

State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

100F37143 Other

10/20

State: MI · Issuer: Bcbs And Bcn
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

C45037 Medicare UPIN

11/20

4318636 Medicaid

12/20

State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

4592984 Medicaid

13/20

State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

0F37143 Medicare ID-Type Unspecified

14/20

State: MI
Medicare ID (Type Unspecified): A Medicare-issued provider identifier whose specific subtype or program context has not been designated.

4101048 Medicaid

15/20

State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

4258298 Medicaid

16/20

State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

3364901 Medicaid

17/20

State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

H34728 Medicare UPIN

18/20

4310182 Medicaid

19/20

State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

2836211 Medicaid

20/20

State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

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