1346457488 NPI number — NORTHWESTERN MICHIGAN DERMATOLOGY

Table of content: (NPI 1346457488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346457488 NPI number — NORTHWESTERN MICHIGAN DERMATOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWESTERN MICHIGAN DERMATOLOGY
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:
1346457488
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 MUNSON AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49686-3580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-935-8717
Provider Business Mailing Address Fax Number:
231-935-9230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 MUNSON AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49686-3580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-935-8717
Provider Business Practice Location Address Fax Number:
231-935-9230
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PENDHARKAR
Authorized Official First Name:
SOUMIT
Authorized Official Middle Name:
SHAM
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
231-935-8717

Provider Taxonomy Codes

  • Taxonomy code: 207ND0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1962511097 . This is a "NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1285743393 . This is a "NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4301063462 . This is a "MI LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4301077553 . This is a "MI LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1437268661 . This is a "NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4301406284 . This is a "MICHIGAN LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1770692873 . This is a "NPI NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1997138 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3347473 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4301067697 . This is a "MI LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4317989 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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