1679502009 NPI number — GENERAL SURGICAL ASSOCIATES PC

Table of content: (NPI 1679502009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679502009 NPI number — GENERAL SURGICAL ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENERAL SURGICAL ASSOCIATES 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:
1679502009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 E MANSION ST
Provider Second Line Business Mailing Address:
SUITE 3E
Provider Business Mailing Address City Name:
MARSHALL
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49068-1559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-781-4267
Provider Business Mailing Address Fax Number:
269-781-2710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 E MANSION ST
Provider Second Line Business Practice Location Address:
SUITE 3E
Provider Business Practice Location Address City Name:
MARSHALL
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49068-1559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-781-4267
Provider Business Practice Location Address Fax Number:
269-781-2710
Provider Enumeration Date:
06/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GORDON
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
269-781-4267

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4301067751 , 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: 020A310990 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: G5056F . This is a "BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 383530765005 . This is a "TRICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CH0788 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 020A312720 . This is a "BCBSM GROUP ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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