1023185162 NPI number — COVENANT PATHOLOGY ASSOCIATES, PC

Table of content: (NPI 1023185162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023185162 NPI number — COVENANT PATHOLOGY ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT PATHOLOGY ASSOCIATES, 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:
MI HEALTH CLINIC
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:
1023185162
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3925 FORTUNE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48603-2287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-459-2300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3925 FORTUNE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAGINAW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48603-2287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-459-2300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STOCKMAN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
989-459-2300

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 38068 . This is a "COMMUNITY CHOICE MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1009460 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CI9309 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 02833 . This is a "PRIORITY HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 029611 . This is a "MIDWEST HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0G31049 . This is a "BLUE CROSS BLUE SHIELD MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 50011958 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0985739 . This is a "HEALTHPLUS MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 136122100 . This is a "US DEPT OF LABOR WORKCOMP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: LP730004 . This is a "M-CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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