1619167657 NPI number — MRS. EVELYN RUTH SOMMARIVA PA-C

Table of content: MRS. EVELYN RUTH SOMMARIVA PA-C (NPI 1619167657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619167657 NPI number — MRS. EVELYN RUTH SOMMARIVA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOMMARIVA
Provider First Name:
EVELYN
Provider Middle Name:
RUTH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WARNER
Provider Other First Name:
EVELYN
Provider Other Middle Name:
RUTH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619167657
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43151 DALCOMA DR
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
CLINTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48038-6306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-286-8720
Provider Business Mailing Address Fax Number:
586-286-8723

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
285 N. LILLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48187-4849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-495-1506
Provider Business Practice Location Address Fax Number:
734-495-1780
Provider Enumeration Date:
07/26/2007

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: 363A00000X , with the licence number:  5601005023 , 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: 0F31794 . This is a "BCBS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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