1184642886 NPI number — ARCHIBALD W. DETTMAN

Table of content: JASMYN TANG (NPI 1427601947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184642886 NPI number — ARCHIBALD W. DETTMAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARCHIBALD W. DETTMAN
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:
SHIAWASSEE FAMILY MEDICINE
Provider Other Organization Name Type Code:
3
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:
1184642886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 N SHIAWASSEE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORUNNA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48817-1435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-743-3415
Provider Business Mailing Address Fax Number:
989-743-6180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 N SHIAWASSEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORUNNA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48817-1435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-743-3415
Provider Business Practice Location Address Fax Number:
989-743-6180
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DETTMAN
Authorized Official First Name:
ARCHIBALD
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
989-743-3415

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  5101006898 , 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: CH2727 . This is a "TRAVELERS MC GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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