1720198039 NPI number — FENTON FAMILY MEDICINE, P.C.

Table of content: (NPI 1720198039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720198039 NPI number — FENTON FAMILY MEDICINE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FENTON FAMILY MEDICINE, 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:
1720198039
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:
445 N FENWAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FENTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48430-2666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-750-6060
Provider Business Mailing Address Fax Number:
810-750-6081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
445 N FENWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FENTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48430-2666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-750-6060
Provider Business Practice Location Address Fax Number:
810-750-6081
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STEIBEL
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
810-750-6060

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  KS051250 , 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: 080B56203 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2509644012 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C3137 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2787144 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0B56203 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: E77396 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com