1629057187 NPI number — DR. MICHAEL J OCCHIETTI MD

Table of content: DR. MICHAEL J OCCHIETTI MD (NPI 1629057187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629057187 NPI number — DR. MICHAEL J OCCHIETTI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OCCHIETTI
Provider First Name:
MICHAEL
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
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:
1629057187
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1711 SOUTH STEPHENSON AVENUE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
IRON MOUNTAIN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-779-9870
Provider Business Mailing Address Fax Number:
906-779-5888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1711 SOUTH STEPHENSON AVENUE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
IRON MOUNTAIN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-776-5250
Provider Business Practice Location Address Fax Number:
906-228-0217
Provider Enumeration Date:
01/12/2006

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: 207X00000X , with the licence number:  MO063234 , 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: 383105579 . This is a "TAX ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 32564300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4318832 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300220077 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com