1679561443 NPI number — DR. TIMOTHY DONALD MACON D.O.,F.C.C.P.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679561443 NPI number — DR. TIMOTHY DONALD MACON D.O.,F.C.C.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACON
Provider First Name:
TIMOTHY
Provider Middle Name:
DONALD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.,F.C.C.P.
Provider Gender Code:
M

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:
1679561443
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
780 N GAVORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STERLING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48659-9703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-654-2168
Provider Business Mailing Address Fax Number:
989-654-2825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
780 N GAVORD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STERLING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48659-9703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-654-2168
Provider Business Practice Location Address Fax Number:
989-654-2825
Provider Enumeration Date:
10/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  TM009037 , 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: 115651012 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 302002 . This is a "CENTRAL HEALTH PLAN OF MI" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4509887 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110216075 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 383563124 . This is a "PPOM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 383563124 . This is a "UNITED HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1007603 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 383563124101 . This is a "COMMUNITY CHOICE OF MICH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1000781 . This is a "MCLAREN HEALTH ADVANTAGE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 122278 . This is a "PREFERRED CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 383563124 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 115651012 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4261168 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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