1194707448 NPI number — MS. THERESA M DURLEY NP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194707448 NPI number — MS. THERESA M DURLEY NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DURLEY
Provider First Name:
THERESA
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DURLEY
Provider Other First Name:
THERESA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1194707448
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 PRESQUE ISLE AVENUE
Provider Second Line Business Mailing Address:
HEALTH CENTER - LOWER GRIES
Provider Business Mailing Address City Name:
MARQUETTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-227-2355
Provider Business Mailing Address Fax Number:
906-227-2332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 PRESQUE ISLE AVENUE
Provider Second Line Business Practice Location Address:
HEALTH CENTER - LOWER GRIES
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-227-2355
Provider Business Practice Location Address Fax Number:
906-227-2332
Provider Enumeration Date:
11/14/2005

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: 367500000X , with the licence number:  4704131080 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 4704131080 , 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: 104654110 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 44337600 . This is a "WISC MEDICAID PIN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: TD131080 . This is a "BLUESHIELD PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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