Provider Demographics
NPI:1043865249
Name:MERIDIAN HEALTH PLAN OF MICHIGAN, INC.
Entity type:Organization
Organization Name:MERIDIAN HEALTH PLAN OF MICHIGAN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:HABER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-206-3252
Mailing Address - Street 1:8735 HENDERSON RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-1143
Mailing Address - Country:US
Mailing Address - Phone:813-206-3252
Mailing Address - Fax:
Practice Address - Street 1:777 WOODWARD AVE STE 600
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-3589
Practice Address - Country:US
Practice Address - Phone:888-773-2647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLCARE OF MICHIGAN HOLDING COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN52653OtherNAIC