1841212701 NPI number — JAN C GROMADA DO

Table of content: JAN C GROMADA DO (NPI 1841212701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841212701 NPI number — JAN C GROMADA DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROMADA
Provider First Name:
JAN
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1841212701
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 LAKE NEPRESSING RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAPEER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-245-9011
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 LAKE NEPESSING RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAPEER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48446-2961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-245-9011
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/23/2006

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: 207V00000X , with the licence number:  JG006098 , 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: 114737651 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 114901620 . This is a "MOLINA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 141205 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1015855 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1G00026 . This is a "HEALTH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C1522 . This is a "MCARE HMO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1654410124 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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