1568629665 NPI number — GREGORY CZARNECKI GREG CZARNECKI

Table of content: GREGORY CZARNECKI GREG CZARNECKI (NPI 1568629665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568629665 NPI number — GREGORY CZARNECKI GREG CZARNECKI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CZARNECKI
Provider First Name:
GREGORY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
GREG CZARNECKI
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CZARNECKI
Provider Other First Name:
GREG
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
GREG CZARNECKI
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1568629665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22190 GARRISON ST
Provider Second Line Business Mailing Address:
302
Provider Business Mailing Address City Name:
DEARBORN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48124-2260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-562-0255
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22190 GARRISON ST
Provider Second Line Business Practice Location Address:
302
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48124-2260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-562-0255
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2008

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: 1223G0001X , with the licence number:  2901011792 , 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)





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