1629128418 NPI number — MERIDIAN PRIMARY CARE PC

Table of content: (NPI 1629128418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629128418 NPI number — MERIDIAN PRIMARY CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERIDIAN PRIMARY CARE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1629128418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2270 JOLLY OAK RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
OKEMOS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48864-4528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-349-6140
Provider Business Mailing Address Fax Number:
517-349-6216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2270 JOLLY OAK RD
Provider Second Line Business Practice Location Address:
SUITE1
Provider Business Practice Location Address City Name:
OKEMOS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48864-4528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-349-6140
Provider Business Practice Location Address Fax Number:
517-349-6216
Provider Enumeration Date:
01/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PERRY
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
517-349-6140

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  DP052522 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: KC064356 , 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)

  • Identifier: 4186985 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4187015 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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