1174632087 NPI number — VANDYKE MEDICAL CLINIC MANAGEMENT CORP

Table of content: (NPI 1174632087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174632087 NPI number — VANDYKE MEDICAL CLINIC MANAGEMENT CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VANDYKE MEDICAL CLINIC MANAGEMENT CORP
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:
1174632087
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19431 VAN DYKE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48234-3323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-893-2010
Provider Business Mailing Address Fax Number:
313-893-3308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19431 VAN DYKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48234-3323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-893-2010
Provider Business Practice Location Address Fax Number:
313-893-3308
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MULLEN
Authorized Official First Name:
ERNEST
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
313-893-2010

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  4301081357 , 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: 4796189 TYPE 10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080H249740 . This is a "BLUE CROSS GROUP PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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