1477534931 NPI number — DR. JOHN WILLIAM POLLEY M.D.

Table of content: DR. JOHN WILLIAM POLLEY M.D. (NPI 1477534931)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477534931 NPI number — DR. JOHN WILLIAM POLLEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLLEY
Provider First Name:
JOHN
Provider Middle Name:
WILLIAM
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:
POLLEY
Provider Other First Name:
JOHN
Provider Other Middle Name:
WILLIAM
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1477534931
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MICHIGAN ST NE # MC845
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503-2560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 MICHIGAN ST NE STE 5201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503-2514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-486-5885
Provider Business Practice Location Address Fax Number:
616-391-1191
Provider Enumeration Date:
11/10/2005

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:  4301403808 , 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: 21623004 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036079739 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0B80405 . This is a "BCBSMI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: BP2135590 . This is a "DEA #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".