1871686766 NPI number — WATERFORD FAMILY PHYSICIANS

Table of content: (NPI 1871686766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871686766 NPI number — WATERFORD FAMILY PHYSICIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WATERFORD FAMILY PHYSICIANS
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:
1871686766
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6620 HIGHLAND RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
WATERFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48327-1682
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-666-9332
Provider Business Mailing Address Fax Number:
248-666-0340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6620 HIGHLAND RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-666-9332
Provider Business Practice Location Address Fax Number:
248-666-0340
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOELKE
Authorized Official First Name:
BRADFORD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
248-666-9332

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010F363130 . This is a "BCBSM GROUP ID NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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