1790704062 NPI number — MRS. DENISE ROSE DAVIS P.A.

Table of content: MRS. DENISE ROSE DAVIS P.A. (NPI 1790704062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790704062 NPI number — MRS. DENISE ROSE DAVIS P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
DENISE
Provider Middle Name:
ROSE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GALLAGHER
Provider Other First Name:
DENISE
Provider Other Middle Name:
ROSE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790704062
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27483 DEQUINDRE RD
Provider Second Line Business Mailing Address:
SUITE 314
Provider Business Mailing Address City Name:
MADISON HEIGHTS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48071-3491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-547-6600
Provider Business Mailing Address Fax Number:
248-547-5696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27483 DEQUINDRE RD
Provider Second Line Business Practice Location Address:
SUITE 314
Provider Business Practice Location Address City Name:
MADISON HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48071-3491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-547-6600
Provider Business Practice Location Address Fax Number:
248-547-5696
Provider Enumeration Date:
07/18/2006

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: 363A00000X , with the licence number:  5601004747 , 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: 700H217350 . This is a "BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1790704062 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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