1245497858 NPI number — NORTHWEST MICHIGAN HEART & VASCULAR SPECIALISTS

Table of content: (NPI 1245497858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245497858 NPI number — NORTHWEST MICHIGAN HEART & VASCULAR SPECIALISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST MICHIGAN HEART & VASCULAR SPECIALISTS
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:
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:
1245497858
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2393 MOMENTUM PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60689-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-935-0335
Provider Business Mailing Address Fax Number:
231-935-0336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3529 W FRONT ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49684-9689
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-935-0335
Provider Business Practice Location Address Fax Number:
231-935-0336
Provider Enumeration Date:
05/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LAUER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
231-935-0335

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  4301075408 , 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: 0602810871 . This is a "BCBS OF MICH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1245497858 . This is a "CORP NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1407890536 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1407890536 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0281087 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0281087 . This is a "BCBS OF MICH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0602810871 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1245497858 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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