1578579595 NPI number — TED SUGIMOTO MD

Table of content: TED SUGIMOTO MD (NPI 1578579595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578579595 NPI number — TED SUGIMOTO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUGIMOTO
Provider First Name:
TED
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1578579595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6416 DEANS HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERRIEN CENTER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49102-9750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-471-7741
Provider Business Mailing Address Fax Number:
269-471-1581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3950 HOLLYWOOD RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49085-9159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-429-0900
Provider Business Practice Location Address Fax Number:
269-408-0996
Provider Enumeration Date:
07/31/2006

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: 208600000X , with the licence number:  4301041051 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 4301041051 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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