1871778647 NPI number — SAGINAW VALLEY FOOT & ANKLE CENTER

Table of content: (NPI 1871778647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871778647 NPI number — SAGINAW VALLEY FOOT & ANKLE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAGINAW VALLEY FOOT & ANKLE CENTER
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:
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:
1871778647
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5400 MACKINAW
Provider Second Line Business Mailing Address:
SUITE 2100
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48604-9549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-790-4662
Provider Business Mailing Address Fax Number:
989-790-7680

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5400 MACKINAW
Provider Second Line Business Practice Location Address:
SUITE 2100
Provider Business Practice Location Address City Name:
SAGINAW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48604-9549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-790-4662
Provider Business Practice Location Address Fax Number:
989-790-7680
Provider Enumeration Date:
12/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TESORO
Authorized Official First Name:
DEREK
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
OWNER PHYSICIAN
Authorized Official Telephone Number:
989-790-4662

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  DT001450 , 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: 3173006 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4857311150 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 480019411 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1198630001 . This is a "MEDICARE SUPPLIER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 11290415 . This is a "CAQH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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