1205827771 NPI number — DR. JAMES PHILIP SERINO O.D.

Table of content: DR. GIOVANNA GIOVANNIELLO M.D. (NPI 1609830280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205827771 NPI number — DR. JAMES PHILIP SERINO O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SERINO
Provider First Name:
JAMES
Provider Middle Name:
PHILIP
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

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:
1205827771
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3695 W PRIMILIA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49201-9395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-783-3916
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 N WISNER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49202-4225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-783-6928
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2005

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: 152W00000X , with the licence number:  4901003057 , 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: 200000004902 . This is a "PHP OF SOUTH MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5892950001 . This is a "DMERC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 410020815 . This is a "PALMETTO GBA RR MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: VCM-0142 . This is a "M-CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 900C811800 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5448465 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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