1497860795 NPI number — MI STREET ORTHOPEDIC SPECIALISTS PC

Table of content: (NPI 1497860795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497860795 NPI number — MI STREET ORTHOPEDIC SPECIALISTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MI STREET ORTHOPEDIC SPECIALISTS 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:
BEREZA & LOVELL ORTHOPEDICS, P.C.
Provider Other Organization Name Type Code:
5
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:
1497860795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 MICHIGAN ST NE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503-2026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-774-9515
Provider Business Mailing Address Fax Number:
616-774-7116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 MICHIGAN ST NE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503-2026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-774-9515
Provider Business Practice Location Address Fax Number:
616-774-7116
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LUMLEY
Authorized Official First Name:
LORI
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
616-774-9515

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com