1740252535 NPI number — SOUTH COUNTY ENT

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 1740252535 NPI number — SOUTH COUNTY ENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH COUNTY ENT
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:
1740252535
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 N SAINT JOSEPH AVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
NILES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49120-2296
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-687-2910
Provider Business Mailing Address Fax Number:
269-687-8770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 N SAINT JOSEPH AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
NILES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49120-2296
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-687-2910
Provider Business Practice Location Address Fax Number:
269-687-8770
Provider Enumeration Date:
02/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIDDLETON
Authorized Official First Name:
MARY
Authorized Official Middle Name:
GEEGAN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
269-684-0259

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4301074195 , 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: DA1319 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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