1821147638 NPI number — MARJORIE A SOPER P.C.

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 1821147638 NPI number — MARJORIE A SOPER P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARJORIE A SOPER 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:
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:
1821147638
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4465 ATLAS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVISON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48423-8707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-579-5757
Provider Business Mailing Address Fax Number:
810-579-5757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12751 S SAGINAW ST
Provider Second Line Business Practice Location Address:
STE 700
Provider Business Practice Location Address City Name:
GRAND BLANC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48439-2751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-579-5757
Provider Business Practice Location Address Fax Number:
810-579-5757
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SOPER
Authorized Official First Name:
MARJORIE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
THERAPIST
Authorized Official Telephone Number:
810-579-5757

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801063883 , 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: 38-1213512 . This is a "TRICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 800894156 . This is a "BLUE CROSS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 037804 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 39940 . This is a "MAGELLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2053431 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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