1295766137 NPI number — DR. LASCELLES PINNOCK M.D

Table of content: DR. LASCELLES PINNOCK M.D (NPI 1295766137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295766137 NPI number — DR. LASCELLES PINNOCK M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PINNOCK
Provider First Name:
LASCELLES
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
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:
1295766137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14575 SOUTHFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLEN PARK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-381-5170
Provider Business Mailing Address Fax Number:
313-381-8790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14575 SOUTHFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALLEN PARK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-381-5170
Provider Business Practice Location Address Fax Number:
313-381-8790
Provider Enumeration Date:
07/06/2006

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: 207Y00000X , with the licence number:  LP042960 , 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: 0255787002 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4033934 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 13242 . This is a "WELLNESS -CHSD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 21165 . This is a "OMNI HMO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 046 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2110638-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 125274 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4440296 . This is a "TEAMSTERS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 48254 . This is a "OMNI CARE CONVENTRY" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: OH23634 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 81165 . This is a "OMNI POS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 000000004774 . This is a "CAPE HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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