1255967667 NPI number — BLUE WATER INTERNAL MEDICINE, PC

Table of content: (NPI 1255967667)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255967667 NPI number — BLUE WATER INTERNAL MEDICINE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE WATER INTERNAL MEDICINE, 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:
1255967667
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1210 10TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT HURON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48060-3406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-662-3505
Provider Business Mailing Address Fax Number:
810-662-3479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1210 10TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT HURON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48060-3406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-622-3505
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
810-662-3505

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4301076169 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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