1629173026 NPI number — JAMES M SHIRILLA MD PC

Table of content: (NPI 1629173026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629173026 NPI number — JAMES M SHIRILLA MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAMES M SHIRILLA MD 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:
1629173026
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 W FLETCHER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALPENA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49707-2301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-354-0845
Provider Business Mailing Address Fax Number:
989-354-2965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 N DIVISION RD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
PETOSKEY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49770-9045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-487-3980
Provider Business Practice Location Address Fax Number:
231-439-0278
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NICKLES
Authorized Official First Name:
HELEN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
BILLING OFFICE MANAGER
Authorized Official Telephone Number:
989-354-0845

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X , with the licence number:  JS036674 , 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: 1102428731 . This is a "BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4177153 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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