1609851153 NPI number — DR. DONALD J TYNES M.D.

Table of content: DR. DONALD J TYNES M.D. (NPI 1609851153)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609851153 NPI number — DR. DONALD J TYNES M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TYNES
Provider First Name:
DONALD
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
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:
TYNES
Provider Other First Name:
DON
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1609851153
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
756 PIPESTONE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON HARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49022-4845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-926-8535
Provider Business Mailing Address Fax Number:
269-926-8528

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
756 PIPESTONE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON HARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49022-4845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-926-8535
Provider Business Practice Location Address Fax Number:
269-926-8528
Provider Enumeration Date:
12/07/2005

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:  4301065652 , 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: 06103A . This is a "BERRIEN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7338232 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 11-01-11-04-82 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: OPO3540 . This is a "MEDICARE GROUP BUSINESS NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 11583 . This is a "HEATH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4662247-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 412153406100 . This is a "COMMUNITY CHOICE OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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