1528094489 NPI number — TAWAS FOOT CLINIC P.C.

Table of content: (NPI 1528094489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528094489 NPI number — TAWAS FOOT CLINIC P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAWAS FOOT CLINIC P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1528094489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 178
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAWAS CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48764-0178
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-362-6558
Provider Business Mailing Address Fax Number:
989-365-7168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
166 M 55
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAWAS CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-362-6558
Provider Business Practice Location Address Fax Number:
989-362-7168
Provider Enumeration Date:
06/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WRIGHT
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
989-362-6558

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  5901001133 , 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: 4310389 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480026004 . This is a "PALMETTO GBA-RR MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 71020000C51005 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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