1104271824 NPI number — RACHEL MARIE HERMAN PA

Table of content: RACHEL MARIE HERMAN PA (NPI 1104271824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104271824 NPI number — RACHEL MARIE HERMAN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERMAN
Provider First Name:
RACHEL
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUGNET
Provider Other First Name:
RACHEL
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104271824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MICHIGAN ST NE
Provider Second Line Business Mailing Address:
MC 845
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503-2560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MICHIGAN ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-391-3431
Provider Business Practice Location Address Fax Number:
616-391-2783
Provider Enumeration Date:
05/02/2016

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: 363A00000X , with the licence number:  5601007841 , 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)