1407635261 NPI number — MS. ADELINA BASTE MCCAULLEY RN

Table of content: DR. RYAN PAUL MATTESON FNP (NPI 1912474479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407635261 NPI number — MS. ADELINA BASTE MCCAULLEY RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCAULLEY
Provider First Name:
ADELINA
Provider Middle Name:
BASTE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN
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:
1407635261
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29774 GUY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48076-1886
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-866-3877
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17520 W 12 MILE RD STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48076-1902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-281-6880
Provider Business Practice Location Address Fax Number:
248-281-6871
Provider Enumeration Date:
09/21/2023

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: 163W00000X , with the licence number:  4704147594 , 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)





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