1114008711 NPI number — MICHAEL GORDON STEWART PHD, CCC-A

Table of content: MICHAEL GORDON STEWART PHD, CCC-A (NPI 1114008711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114008711 NPI number — MICHAEL GORDON STEWART PHD, CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEWART
Provider First Name:
MICHAEL
Provider Middle Name:
GORDON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD, CCC-A
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:
1114008711
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 HEALTH PROFESSIONS BLDG
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MT PLEASANT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48859-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-774-3904
Provider Business Mailing Address Fax Number:
989-774-1891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 HEALTH PROFESSIONS BLDG
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT PLEASANT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48859-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-774-3904
Provider Business Practice Location Address Fax Number:
989-774-1891
Provider Enumeration Date:
10/18/2006

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: 231H00000X , with the licence number:  1601000250 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 237600000X , with the licence number: 1601000250 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1601000250 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 640C32605 . This is a "BCBS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 00719898 . This is a "ASHA NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 40-4683793 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90-2628470 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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