1013456201 NPI number — TAMIKA DAVIS ADULT-GERONTOLOGY PR

Table of content: TAMIKA DAVIS ADULT-GERONTOLOGY PR (NPI 1013456201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013456201 NPI number — TAMIKA DAVIS ADULT-GERONTOLOGY PR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
TAMIKA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ADULT-GERONTOLOGY PR
Provider Gender Code:
F

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:
1013456201
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 W MONROE ST STE 1200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60603-2420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-733-9730
Provider Business Mailing Address Fax Number:
773-866-8014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18610 FENKELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48223-2378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-723-6000
Provider Business Practice Location Address Fax Number:
313-424-4058
Provider Enumeration Date:
02/21/2017

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: 363LA2200X , with the licence number:  224736 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP2300X , with the licence number: 4704272126 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 527474 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".