1265425177 NPI number — DR. JOHN M DYSART MD

Table of content: DR. JOHN M DYSART MD (NPI 1265425177)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265425177 NPI number — DR. JOHN M DYSART MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DYSART
Provider First Name:
JOHN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1265425177
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MICHIGAN ST NE
Provider Second Line Business Mailing Address:
MC 845
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503-2560
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:
3220 DISCOVERY DRIVE
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-484-0004
Provider Business Practice Location Address Fax Number:
517-484-7241
Provider Enumeration Date:
08/25/2005

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: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0202X , with the licence number: JD063672 , 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: L3338287 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 85305 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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