1043473655 NPI number — DR. TYANNE LEE DOSH M.D., M.S.

Table of content: DR. TYANNE LEE DOSH M.D., M.S. (NPI 1043473655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043473655 NPI number — DR. TYANNE LEE DOSH M.D., M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOSH
Provider First Name:
TYANNE
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., M.S.
Provider Gender Code:
F

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:
1043473655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26374 NETWORK PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60673-1263
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-225-3895
Provider Business Mailing Address Fax Number:
906-225-4562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
580 W COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-2736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-225-3895
Provider Business Practice Location Address Fax Number:
906-225-4562
Provider Enumeration Date:
07/03/2008

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: 2084P0800X , with the licence number:  43423 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1043473655 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100133350 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".