1629263520 NPI number — WESTERN WAYNE FAMILY PHYSICIANS, PLC

Table of content: (NPI 1629263520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629263520 NPI number — WESTERN WAYNE FAMILY PHYSICIANS, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN WAYNE FAMILY PHYSICIANS, PLC
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:
WESTERN WAYNE PHYSICIANS, PLC
Provider Other Organization Name Type Code:
3
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:
1629263520
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7445 ALLEN RD
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
ALLEN PARK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48101-1963
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-386-5500
Provider Business Mailing Address Fax Number:
313-386-3444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7445 ALLEN RD
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
ALLEN PARK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48101-1963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-386-5500
Provider Business Practice Location Address Fax Number:
313-386-3444
Provider Enumeration Date:
09/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER / SECRETARY
Authorized Official Telephone Number:
313-386-5500

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3506382 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4172620 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4545062 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4172611 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: CD8151 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CC4542 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4545053 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4281910 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4572954 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: CG3535 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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