1770671299 NPI number — KORNELIS OOSTHOEK PT

Table of content: KORNELIS OOSTHOEK PT (NPI 1770671299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770671299 NPI number — KORNELIS OOSTHOEK PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OOSTHOEK
Provider First Name:
KORNELIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1770671299
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1247 CASTLEWOOD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE LAKE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48386-3720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-673-6980
Provider Business Mailing Address Fax Number:
248-673-7497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2050 N HAGGERTY RD STE 280
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48187-3796
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-844-0800
Provider Business Practice Location Address Fax Number:
734-844-0808
Provider Enumeration Date:
10/10/2006

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: 225100000X , with the licence number:  5501003952 , 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: 650F324550 . This is a "BLUE CROSS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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