1407935042 NPI number — MARK C KOMOROWSKI MD

Table of content: MARK C KOMOROWSKI MD (NPI 1407935042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407935042 NPI number — MARK C KOMOROWSKI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOMOROWSKI
Provider First Name:
MARK
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1407935042
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 S TRUMBULL STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAY CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-893-9393
Provider Business Mailing Address Fax Number:
989-893-9975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 S TRUMBULL STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAY CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-893-9393
Provider Business Practice Location Address Fax Number:
989-893-9975
Provider Enumeration Date:
11/03/2006

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: 208200000X , with the licence number:  MK050674 , 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: 295089810 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0980939 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2400900501 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".