1083615025 NPI number — DR. GARY A SHINTANI DO

Table of content: DR. GARY A SHINTANI DO (NPI 1083615025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083615025 NPI number — DR. GARY A SHINTANI DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHINTANI
Provider First Name:
GARY
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1083615025
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6545
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49696-6545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-922-9270
Provider Business Mailing Address Fax Number:
231-922-9271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 HOBART ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CADILLAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49601-2331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-876-7200
Provider Business Practice Location Address Fax Number:
231-876-6830
Provider Enumeration Date:
08/01/2005

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: 207R00000X , with the licence number:  5101013542 , 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: 4236844 . This is a "MOLINA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110H310180 . This is a "BC BILLING NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 127835 . This is a "PREF CHOICE BILLING NUMBE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 27544 . This is a "PRIORITY HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 383552631057 . This is a "COMM CHOICE BILLING NUMBE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4236844 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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