1669454559 NPI number — ENDOCRINOLOGY AND DIABETES CENTER OF PORT HURON PLLC

Table of content: (NPI 1669454559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669454559 NPI number — ENDOCRINOLOGY AND DIABETES CENTER OF PORT HURON PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENDOCRINOLOGY AND DIABETES CENTER OF PORT HURON PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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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:
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NPI Number Information

NPI Number:
1669454559
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4190 24TH AVE
Provider Second Line Business Mailing Address:
SUITE: 201
Provider Business Mailing Address City Name:
FORT GRATIOT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48059-3882
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-989-7478
Provider Business Mailing Address Fax Number:
810-989-7644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4190 24TH AVE
Provider Second Line Business Practice Location Address:
SUITE: 201
Provider Business Practice Location Address City Name:
FORT GRATIOT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48059-3882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-989-7478
Provider Business Practice Location Address Fax Number:
810-989-7644
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
REDDY
Authorized Official First Name:
SUSHMA
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL PARTNER
Authorized Official Telephone Number:
810-989-7478

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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