1194798181 NPI number — STEPHANIE ANN GARSTECK-POLAK CRNA

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 1194798181 NPI number — STEPHANIE ANN GARSTECK-POLAK CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARSTECK-POLAK
Provider First Name:
STEPHANIE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRESSLER
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194798181
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44201 DEQUINDRE RD
Provider Second Line Business Mailing Address:
ATTN SURGICAL SERVICES
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48085-1117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-964-3012
Provider Business Mailing Address Fax Number:
248-964-3012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44201 DEQUINDRE RD
Provider Second Line Business Practice Location Address:
ATTN SURGICAL SERVICES
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48085-1117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-964-3012
Provider Business Practice Location Address Fax Number:
248-964-3012
Provider Enumeration Date:
02/09/2006

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: 367500000X , with the licence number:  4704153624 , 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: 430042552 . This is a "TRAVELERS MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: SG153624 . This is a "BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3227635 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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