1033290796 NPI number — FOWLERVILLE MEDICAL CENTER, PLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033290796 NPI number — FOWLERVILLE MEDICAL CENTER, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOWLERVILLE MEDICAL CENTER, PLC
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:
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:
1033290796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 E VAN RIPER RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
FOWLERVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48836-7947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-223-7900
Provider Business Mailing Address Fax Number:
517-223-7635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 E VAN RIPER RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
FOWLERVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48836-7947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-223-7900
Provider Business Practice Location Address Fax Number:
517-223-7635
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRACY
Authorized Official First Name:
NORINE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
517-223-7900

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4301060017 , 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: 0477259 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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