1992937148 NPI number — HILLSDALE PEDIATRICS CLINIC PC

Table of content: (NPI 1992937148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992937148 NPI number — HILLSDALE PEDIATRICS CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HILLSDALE PEDIATRICS CLINIC PC
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:
HILLSDALE PEDIATRICS
Provider Other Organization Name Type Code:
4
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:
1992937148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1131 N OSSEO RD
Provider Second Line Business Mailing Address:
P.O. BOX 187
Provider Business Mailing Address City Name:
HILLSDALE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49242-9714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-523-3695
Provider Business Mailing Address Fax Number:
517-523-3311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
451 HIDDEN MEADOWS DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
HILLSDALE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49242-9812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-437-8325
Provider Business Practice Location Address Fax Number:
517-437-8327
Provider Enumeration Date:
08/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SACKMAN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
517-437-8325

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X , with the licence number:  MS086960 , 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: 3503013872 . This is a "BCBSM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 105336218 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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