1629240965 NPI number — SAMUEL J MUCCI M.D.P.C.

Table of content: (NPI 1629240965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629240965 NPI number — SAMUEL J MUCCI M.D.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMUEL J MUCCI M.D.P.C.
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:
1629240965
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15590 W 13 MILE RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
BEVERLY HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48025-5642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-283-1115
Provider Business Mailing Address Fax Number:
248-283-1119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15590 W 13 MILE RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BEVERLY HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48025-5642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-283-1115
Provider Business Practice Location Address Fax Number:
248-283-1119
Provider Enumeration Date:
03/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BARC
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MEDICAL BILLER
Authorized Official Telephone Number:
248-283-1115

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4301067463 , 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: 2406314511 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 103269170 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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