1003809005 NPI number — DR. JAMES A FUGAZZI M.D,

Table of content: DR. JAMES A FUGAZZI M.D, (NPI 1003809005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003809005 NPI number — DR. JAMES A FUGAZZI M.D,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUGAZZI
Provider First Name:
JAMES
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D,
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003809005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1447 N HARRISON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48602-4727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-583-5250
Provider Business Mailing Address Fax Number:
989-583-5259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5400 MACKINAW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAGINAW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48604-9515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-583-5250
Provider Business Practice Location Address Fax Number:
989-583-5259
Provider Enumeration Date:
08/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  35-086184 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: JF076329 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4758357 . This is a "MI MEDICAID-OH LOCATIONS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0N24000016 . This is a "MI MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00431152 . This is a "RR MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4758357 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2574003 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00246120 . This is a "RR MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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