1568413482 NPI number — DR. MARIE G WALSH MD

Table of content: DR. MARIE G WALSH MD (NPI 1568413482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568413482 NPI number — DR. MARIE G WALSH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALSH
Provider First Name:
MARIE
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1568413482
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1239
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48099-1239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-824-6600
Provider Business Mailing Address Fax Number:
248-324-1477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1985 GRATIOT AVE
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
MARYSVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48040-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-364-5050
Provider Business Practice Location Address Fax Number:
810-364-5688
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: 207R00000X , with the licence number:  4301074465 , 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: 4872208-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1568413482 . This is a "NPI #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0D40029 . This is a "BCBS GROUP PIN FOR LAPEER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1609101807 . This is a "NPI GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: MA074465 . This is a "STATE ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 70-0-F32947-0 . This is a "BCBS CPIN #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1106323752 . This is a "BCBS ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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