1134304595 NPI number — DOWNRIVER ENT PC

Table of content: (NPI 1134304595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134304595 NPI number — DOWNRIVER ENT PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOWNRIVER ENT PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1134304595
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14575 SOUTHFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLEN PARK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48101-2640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-381-5170
Provider Business Mailing Address Fax Number:
313-381-8790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14575 SOUTHFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALLEN PARK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48101-2640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-381-5170
Provider Business Practice Location Address Fax Number:
313-381-8790
Provider Enumeration Date:
01/04/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PINNOCK
Authorized Official First Name:
LASCELLES
Authorized Official Middle Name:
Authorized Official Title or Position:
OTOLARYNGOLOGY
Authorized Official Telephone Number:
313-381-5170

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: LP042960 , 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)