1740214824 NPI number — FAMILY FOOT HEALTH PC

Table of content: (NPI 1740214824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740214824 NPI number — FAMILY FOOT HEALTH PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY FOOT HEALTH 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:
1740214824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 E CHICAGO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLDWATER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-278-6394
Provider Business Mailing Address Fax Number:
517-278-4394

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 E CHICAGO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLDWATER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-278-6394
Provider Business Practice Location Address Fax Number:
517-278-4394
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOODHAMS
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
517-278-6394

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  LW000696 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 48-0A21007-0 . This is a "BLUE CROSS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1349989 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 485125110 . This is a "BLUE CROSS BLUE SCHEILD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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