1811041890 NPI number — LENISE A. BANSE, M.D.,P.C.

Table of content: (NPI 1811041890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811041890 NPI number — LENISE A. BANSE, M.D.,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LENISE A. BANSE, M.D.,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:
NORTHEAST FAMILY DERMATOLOGY CENTER
Provider Other Organization Name Type Code:
5
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:
1811041890
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
42452 HAYES RD
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
CLINTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48038-6771
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-263-3130
Provider Business Mailing Address Fax Number:
586-263-5183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42452 HAYES RD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48038-6771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-263-3130
Provider Business Practice Location Address Fax Number:
586-263-5183
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BANSE
Authorized Official First Name:
LENISE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
586-263-3130

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  4301047653 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207NP0225X , with the licence number: 4301047653 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X , with the licence number: 4301047653 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 101151 . This is a "PREFERRED CHOICES" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0500688 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4037111 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 131180573496 . This is a "HUMANA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: DR500262 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0705006881 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 900013288 . This is a "PRIORITY HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 101151 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 131180573496 . This is a "HUMANA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 155665 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0500688001 . This is a "MEDICARE PLUS BLUE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2806900 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80862B . This is a "HEALTH ALLIANCE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: MO22874 . This is a "TRICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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