1114986528 NPI number — MISS SHANNON MAE MERTES PTA

Table of content: MISS SHANNON MAE MERTES PTA (NPI 1114986528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114986528 NPI number — MISS SHANNON MAE MERTES PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MERTES
Provider First Name:
SHANNON
Provider Middle Name:
MAE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

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:
1114986528
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36306 UNION LK RD
Provider Second Line Business Mailing Address:
APT 204
Provider Business Mailing Address City Name:
HARRISON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-291-8203
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
49050 SCHOENHERR RD
Provider Second Line Business Practice Location Address:
STE 600
Provider Business Practice Location Address City Name:
SHELBY TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-566-8913
Provider Business Practice Location Address Fax Number:
586-566-8739
Provider Enumeration Date:
03/23/2006

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: 225200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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