1619964715 NPI number — MIDLAND ORAL & MAXILLOFACIAL SURGERY P.C.

Table of content: (NPI 1619964715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619964715 NPI number — MIDLAND ORAL & MAXILLOFACIAL SURGERY P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDLAND ORAL & MAXILLOFACIAL SURGERY P.C.
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:
MT. PLEASANT ORAL & MAXILLOFACIAL SURGERY
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:
1619964715
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6112 MERLIN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48640-7358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-839-9979
Provider Business Mailing Address Fax Number:
989-839-9553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6112 MERLIN CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-839-9979
Provider Business Practice Location Address Fax Number:
989-839-9553
Provider Enumeration Date:
10/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BOWERS
Authorized Official First Name:
SHIANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
FINANCIAL DEPT
Authorized Official Telephone Number:
989-839-9979

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2993779 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4274317 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4285455 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3487124 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4263986 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2847912 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4274291 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4274282 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4274308 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3487133 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 426977 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4297311 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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