1568413367 NPI number — HENRY M JURASEK M.D.

Table of content: HENRY M JURASEK M.D. (NPI 1568413367)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568413367 NPI number — HENRY M JURASEK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JURASEK
Provider First Name:
HENRY
Provider Middle Name:
M
Provider Name Prefix Text:
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:
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:
1568413367
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19020 FORT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERVIEW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48193-6701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-362-5100
Provider Business Mailing Address Fax Number:
734-362-5147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19020 FORT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERVIEW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48193-6701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-362-5100
Provider Business Practice Location Address Fax Number:
734-362-5147
Provider Enumeration Date:
05/15/2006

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: 207Q00000X , with the licence number:  4301078292 , 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: 7442675 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CC3713 . This is a "RR MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 16742 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2418133 . This is a "UHC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700H21076 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 139214 . This is a "MERCY CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4301078292 . This is a "PHYSICIAN LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 6684867 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4621093 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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