1487939757 NPI number — MITAL TAMAKUWALA RPT

Table of content: MITAL TAMAKUWALA RPT (NPI 1487939757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487939757 NPI number — MITAL TAMAKUWALA RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAMAKUWALA
Provider First Name:
MITAL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPT
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:
1487939757
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 S MISSION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MT PLEASANT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48858-2846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-772-7755
Provider Business Mailing Address Fax Number:
989-772-7750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 ECORSE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YPSILANTI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48198-5734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-483-1000
Provider Business Practice Location Address Fax Number:
734-483-1010
Provider Enumeration Date:
10/18/2011

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: 225100000X , with the licence number:  5501015287 , 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: 5501015287 . This is a "STATE OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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