1912989948 NPI number — DAN S SCIUCA MD

Table of content: DAN S SCIUCA MD (NPI 1912989948)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912989948 NPI number — DAN S SCIUCA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCIUCA
Provider First Name:
DAN
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1912989948
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1659 TRAIL RIDGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49024-4900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-998-5398
Provider Business Mailing Address Fax Number:
269-341-7781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1659 TRAIL RIDGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-998-5398
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2005

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: 207R00000X , with the licence number:  4301078831 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 4301078831 , 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: 4347244 10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 700G560080 . This is a "BCBS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 382317300 140 . This is a "COMM CHOICE MI-IM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 382317300 154 . This is a "COMM CHOICE MI-TR" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4601303 10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 143068 . This is a "GREAT LAKES HEALTH PLAN-T" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 382317300 107 . This is a "COMM CHOICE MI-WP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4460009 10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4848285 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1107500612 . This is a "BCBS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4938130 10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0G56008 . This is a "MEDICARE GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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