1790773646 NPI number — DR. MARIE LOUISE FOX O.D.

Table of content: (NPI 1124425699)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790773646 NPI number — DR. MARIE LOUISE FOX O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOX
Provider First Name:
MARIE
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

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:
1790773646
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6101 NEWPORT RD
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49002-9233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-382-6500
Provider Business Mailing Address Fax Number:
269-382-2286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6101 NEWPORT RD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49002-9233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-382-6500
Provider Business Practice Location Address Fax Number:
269-382-2286
Provider Enumeration Date:
10/13/2005

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: 152W00000X , with the licence number:  4901004197 , 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: 381734365 . This is a "TAX ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4901004197 . This is a "LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 17800 . This is a "SPECTERA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 900C947460 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2230146 . This is a "UHC,IBA,PHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4536386 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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