1033105630 NPI number — DR. JOHN PATRICK MULLALLY MD

Table of content: (NPI 1891142360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033105630 NPI number — DR. JOHN PATRICK MULLALLY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULLALLY
Provider First Name:
JOHN
Provider Middle Name:
PATRICK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1033105630
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1117 STONE ST
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
PORT HURON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-966-4540
Provider Business Mailing Address Fax Number:
810-966-4549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1117 STONE ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
PORT HURON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-966-4540
Provider Business Practice Location Address Fax Number:
810-966-4549
Provider Enumeration Date:
09/20/2005

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: 207Q00000X , with the licence number:  4301059921 , 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: 0740124 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104299 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: G13412 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4352066 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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