1275509036 NPI number — TAWAS BAY FAMILY PRACTICE PC

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 1275509036 NPI number — TAWAS BAY FAMILY PRACTICE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAWAS BAY FAMILY PRACTICE PC
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:
1275509036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 369
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAWAS CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48764-0369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-362-3447
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
541 W LAKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAWAS CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48763-5105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-362-3447
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HEILIG
Authorized Official First Name:
SUZANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
MA
Authorized Official Telephone Number:
989-362-5688

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4301033122 , 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: 080012620 L0601 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0803518971 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 16056 . This is a "BLUE CROSS BLUE SHIELD FACILITY" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2897941 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2897941 . This is a "MOLINA HEALTHCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CC00000010 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com