1265551097 NPI number — JENNIFER BRYCE PA-C

Table of content: JENNIFER BRYCE PA-C (NPI 1265551097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265551097 NPI number — JENNIFER BRYCE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYCE
Provider First Name:
JENNIFER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1265551097
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
42557 WOODWARD AVE
Provider Second Line Business Mailing Address:
STE 130
Provider Business Mailing Address City Name:
BLOOMFIELD HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48304-5206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-322-3088
Provider Business Mailing Address Fax Number:
248-322-4175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 WILLIAM CARLS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COMMERCE TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48382-2201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-937-4764
Provider Business Practice Location Address Fax Number:
248-937-4729
Provider Enumeration Date:
03/29/2007

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: 363AM0700X , with the licence number:  5601002383 , 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: DS0605 . This is a "RAIL ROAD MEDICARE GROUP PIN MHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: MI4989416 . This is a "MEDICARE PTAN MHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: MI4989 . This is a "MEDICARE GROUP PTAN MHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1265551097 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500H274490 . This is a "BCBSM GROUP PIN MHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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