1205871548 NPI number — FAMILY MEDICAL ASSOCIATES

Table of content: (NPI 1205871548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205871548 NPI number — FAMILY MEDICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICAL ASSOCIATES
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:
1205871548
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 LANSING ST
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48813-2400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-543-7720
Provider Business Mailing Address Fax Number:
517-543-1125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 LANSING ST
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48813-2400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-543-7720
Provider Business Practice Location Address Fax Number:
517-543-1125
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BALGER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
517-543-7720

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  007654 , 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: 01-00332 . This is a "PHYSICIANS HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 52310314 . This is a "BLUE CARE NETWORK ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0852310314 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 007654 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2115222 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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