1194786475 NPI number — ALEATHA D REITSMA MATHIAS MD

Table of content: ALEATHA D REITSMA MATHIAS MD (NPI 1194786475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194786475 NPI number — ALEATHA D REITSMA MATHIAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REITSMA MATHIAS
Provider First Name:
ALEATHA
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1194786475
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 FRANK LLOYD WRIGHT DR
Provider Second Line Business Mailing Address:
PO BOX 0446 - LOBBY J
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48105-9484
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:
5301 E HURON RIVER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YPSILANTI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48197-1051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-336-6307
Provider Business Practice Location Address Fax Number:
734-712-3855
Provider Enumeration Date:
03/28/2006

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: 207R00000X , with the licence number:  4301072313 , 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: 07878 . This is a "BCBS - ER LOCATION" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 9236800 . This is a "DAKOTACARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 14857 . This is a "AVERA HEALTH PLAN" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 5682027 . This is a "FIRST HEALTH" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 49409 . This is a "SIOUX VALLEY HEALTH PLAN" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: H53025 . This is a "COVENTRY HEALTH CARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 04-08715 . This is a "MEDICA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1484964 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 249977 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 426038405 . This is a "SELECTFIRST" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 720911046506 . This is a "PREFERRED ONE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0484964 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112262800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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