1871650291 NPI number — DR. PRISCILLA WADE PH.D

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871650291 NPI number — DR. PRISCILLA WADE PH.D

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

WADE

Provider First Name:

PRISCILLA

Provider Middle Name:

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

PH.D

Provider Gender Code:

F

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:

1871650291

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/04/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 4455

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

EAST LANSING

Provider Business Mailing Address State Name:

MI

Provider Business Mailing Address Postal Code:

48826-4455

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

517-336-7366

Provider Business Mailing Address Fax Number:

517-336-0808

Provider First Line Business Practice Location Address:

4123 OKEMOS RD STE 15

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

OKEMOS

Provider Business Practice Location Address State Name:

MI

Provider Business Practice Location Address Postal Code:

48864-2818

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

517-336-7366

Provider Business Practice Location Address Fax Number:

517-336-0808

Provider Enumeration Date:

01/03/2007

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 103T00000X , with the licence number:  6301007011 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 063276 . This is a "CONNECTICUT GENERAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 063276 . This is a "GENERAL MOTORS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 1016708 . This is a "MCLAREN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 11291411 . This is a "BLUE CROSS TRUST" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 68OC34678 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 78357 . This is a "CONNECTICUT GENERAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: A029412 . This is a "VENDOR NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: MI5228936 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: R67036 . This is a "MAGELLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 03626 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 228936000 . This is a "MAGELLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".