1497743264 NPI number — HOLLY AYN CRONKRIGHT PAC

Table of content: HOLLY AYN CRONKRIGHT PAC (NPI 1497743264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497743264 NPI number — HOLLY AYN CRONKRIGHT PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRONKRIGHT
Provider First Name:
HOLLY
Provider Middle Name:
AYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SWEARINGEN
Provider Other First Name:
HOLLY
Provider Other Middle Name:
AYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497743264
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2782 S OTSEGO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAYLORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49735-9404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-497-2500
Provider Business Mailing Address Fax Number:
989-732-6577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2782 S OTSEGO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAYLORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49735-9404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-497-2500
Provider Business Practice Location Address Fax Number:
989-732-6577
Provider Enumeration Date:
10/06/2005

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: 363A00000X , with the licence number:  5601003438 , 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: P00214270 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 010G27604 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1010143 . This is a "MCLAREN HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 139500 . This is a "GREAT LAKES HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 253 . This is a "COMMUNITY CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080G310660 . This is a "BCBS MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1010143 . This is a "HEALTH ADVANTAGE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3500576 . This is a "MOLINA HEALTH CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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