1275687147 NPI number — ROY B PARKE D.O.

Table of content: (NPI 1275687147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275687147 NPI number — ROY B PARKE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROY B PARKE D.O.
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:
BUCHANAN FAMILY MEDICAL CENTER
Provider Other Organization Name Type Code:
3
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:
1275687147
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1045 E FRONT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUCHANAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49107-8474
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-695-5540
Provider Business Mailing Address Fax Number:
269-695-0412

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1045 E FRONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUCHANAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49107-8474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-695-5540
Provider Business Practice Location Address Fax Number:
269-695-0412
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ERNSBERGER
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
269-695-5540

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  5101010822 , 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: 0877052 . This is a "BCBSM PROVIDER #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0P302600003 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0P30260006 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5111155 . This is a "BCBSM PROVIDER #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0A11219 . This is a "BCBSM PROVIDER #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5113009 . This is a "BCBSM PROVIDER #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2575222 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5111148 . This is a "BCBSM PROVIDER NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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