1861451742 NPI number — DR. BROCK WELLS HORSLEY D.O.

Table of content: DR. BROCK WELLS HORSLEY D.O. (NPI 1861451742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861451742 NPI number — DR. BROCK WELLS HORSLEY D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HORSLEY
Provider First Name:
BROCK
Provider Middle Name:
WELLS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1861451742
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:
602 BEECH ST
Provider Second Line Business Mailing Address:
STE 3210
Provider Business Mailing Address City Name:
CLARE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48617-1466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-802-8464
Provider Business Mailing Address Fax Number:
989-802-8815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 BEECH ST
Provider Second Line Business Practice Location Address:
STE 3210
Provider Business Practice Location Address City Name:
CLARE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48617-1466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-802-8464
Provider Business Practice Location Address Fax Number:
989-802-8815
Provider Enumeration Date:
03/21/2006

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: 207Q00000X , with the licence number:  5101014871 , 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: 0101842 . This is a "PHYSICIANS HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 610677100 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0853701105 . This is a "BCBS OF MICHIGAN NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1012731 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 114637450 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com