1417935453 NPI number — STEPHEN C SLAJUS DO

Table of content: STEPHEN C SLAJUS DO (NPI 1417935453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417935453 NPI number — STEPHEN C SLAJUS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SLAJUS
Provider First Name:
STEPHEN
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1417935453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 243
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NIAGARA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54151-0243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-251-3555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1721 S STEPHENSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRON MOUNTAIN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49801-3637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-396-4443
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2006

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: 207X00000X , with the licence number:  5101009759 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: SS009759 , 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: 205220004 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 30052700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3011680 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".