1932317450 NPI number — ALLAN D. NELSON, M.D.

Table of content: (NPI 1932317450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932317450 NPI number — ALLAN D. NELSON, M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLAN D. NELSON, M.D.
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:
PENTWATER FAMILY PRACTICE
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:
1932317450
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 619
Provider Second Line Business Mailing Address:
500 HANCOCK ST
Provider Business Mailing Address City Name:
PENTWATER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49449-0619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-869-7051
Provider Business Mailing Address Fax Number:
231-869-5536

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 HANCOCK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENTWATER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49449-0619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-869-7051
Provider Business Practice Location Address Fax Number:
231-869-5536
Provider Enumeration Date:
05/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
ALLAN
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
231-869-7051

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  4301036682 , 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: 2107294 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0640001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com