1578766952 NPI number — VANIA RAYKOVA MD

Table of content: VANIA RAYKOVA MD (NPI 1578766952)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578766952 NPI number — VANIA RAYKOVA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAYKOVA
Provider First Name:
VANIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1578766952
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 779
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAWAS CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48764-0779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-362-9411
Provider Business Mailing Address Fax Number:
989-362-9925

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 S CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HALE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48739-9272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-728-4211
Provider Business Practice Location Address Fax Number:
989-728-4334
Provider Enumeration Date:
06/06/2007

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: 207Q00000X , with the licence number:  C54998 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 4301084171 , 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: 700E012740 . This is a "BCBSM GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1235131137 . This is a "BCBSM - BLH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1578766952 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".