1821140799 NPI number — TERRANCE L WALSH PA

Table of content: TERRANCE L WALSH PA (NPI 1821140799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821140799 NPI number — TERRANCE L WALSH PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALSH
Provider First Name:
TERRANCE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

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:
1821140799
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1273 N 72ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HART
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49420-8914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-873-3087
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 N ATKINSON DR
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
LUDINGTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49431-1953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-843-3717
Provider Business Practice Location Address Fax Number:
231-845-6198
Provider Enumeration Date:
01/18/2007

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: 363AS0400X , with the licence number:  5601001538 , 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)





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