1861479669 NPI number — DR. JAMES G CLAY DPM

Table of content: DR. JAMES G CLAY DPM (NPI 1861479669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861479669 NPI number — DR. JAMES G CLAY DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLAY
Provider First Name:
JAMES
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1861479669
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4310 LEONARD ST NW
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
WALKER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-453-6329
Provider Business Mailing Address Fax Number:
616-453-1725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
669 BALDWIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JENISON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49428-7903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-457-7171
Provider Business Practice Location Address Fax Number:
616-457-1121
Provider Enumeration Date:
12/22/2005

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: 213E00000X , with the licence number:  5901001439 , 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: 480006462 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 340402 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: JC001439 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".