1982630612 NPI number — CYNTHIA L GLASSON INC

Table of content: (NPI 1982630612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982630612 NPI number — CYNTHIA L GLASSON INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CYNTHIA L GLASSON INC
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:
WALDON FAMILY MEDICINE
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:
1982630612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3003 S BALDWIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORION
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48359-2358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-391-9090
Provider Business Mailing Address Fax Number:
248-391-9210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3003 S BALDWIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORION
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48359-2358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-391-9090
Provider Business Practice Location Address Fax Number:
248-391-9210
Provider Enumeration Date:
06/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GLASSON
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-391-9090

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  CG011459 , 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: 0F32366 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0F32366 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3364670 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: F43394 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 01000827 . This is a "HEALTH PLUS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1982630612 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4294873 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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