1013193754 NPI number — TRACY CHASE GROVES CRNA

Table of content: SARAH DIESING (NPI 1124787288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013193754 NPI number — TRACY CHASE GROVES CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROVES
Provider First Name:
TRACY
Provider Middle Name:
CHASE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHASE
Provider Other First Name:
TRACY
Provider Other Middle Name:
LARAINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013193754
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16001 W 9 MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48075-4818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-849-5806
Provider Business Mailing Address Fax Number:
248-849-5489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16001 W 9 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48075-4818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-849-5806
Provider Business Practice Location Address Fax Number:
248-849-5489
Provider Enumeration Date:
01/11/2008

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: 367500000X , with the licence number:  4704231405 , 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)