1104816511 NPI number — CHARLES J TAUNT JR. DO

Table of content: CHARLES J TAUNT JR. DO (NPI 1104816511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104816511 NPI number — CHARLES J TAUNT JR. DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAUNT
Provider First Name:
CHARLES
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
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:
1104816511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2815 S PENNSYLVANIA AVE
Provider Second Line Business Mailing Address:
STE 204
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48910-3496
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-267-0200
Provider Business Mailing Address Fax Number:
517-267-1877

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2815 S PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
STE 204
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48910-3496
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-267-0200
Provider Business Practice Location Address Fax Number:
517-267-1877
Provider Enumeration Date:
10/26/2005

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: 207XS0114X , with the licence number:  CT014232 , 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: 2053311925 . This is a "BLUES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4947523 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7424589 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5331119 . This is a "BCN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200000006523 . This is a "PHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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