1831190461 NPI number — RENUKA M PATEL M.D.

Table of content: RENUKA M PATEL M.D. (NPI 1831190461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831190461 NPI number — RENUKA M PATEL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATEL
Provider First Name:
RENUKA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1831190461
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2800 SPRING ARBOR RD STE 102
Provider Second Line Business Mailing Address:
PO BOX 905
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49203-3895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-783-2612
Provider Business Mailing Address Fax Number:
517-783-5991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 N EAST AVE
Provider Second Line Business Practice Location Address:
IMAGING DEPARTMENT
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49201-1753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-783-2612
Provider Business Practice Location Address Fax Number:
517-783-5991
Provider Enumeration Date:
08/04/2005

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: 2085R0202X , with the licence number:  4301044604 , 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: 4301044604 . This is a "STATE OF MICHIGAN MEDICAL LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4383939 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3003802611 . This is a "BCBS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 300129519 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".