1023187374 NPI number — MCGH COMPREHENSIVE BREAST SCREENING CENTER LLC

Table of content: (NPI 1023187374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023187374 NPI number — MCGH COMPREHENSIVE BREAST SCREENING CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCGH COMPREHENSIVE BREAST SCREENING CENTER LLC
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:
MCRMC COMPREHENSIVE BREAST HEALTH CENTER
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:
1023187374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43900 GARFIELD RD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
CLINTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48038-1128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-412-5150
Provider Business Mailing Address Fax Number:
586-412-5165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43900 GARFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48038-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-412-5150
Provider Business Practice Location Address Fax Number:
586-412-5165
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LISTON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF TREASURY
Authorized Official Telephone Number:
586-741-4156

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , 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: 4458682 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4458691 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4458726 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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