1881675163 NPI number — FRANK BAGNASCO MD PC

Table of content: (NPI 1881675163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881675163 NPI number — FRANK BAGNASCO MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FRANK BAGNASCO MD PC
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:
1881675163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
07/17/2009
NPI Reactivation Date:
03/09/2011

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44555 WOODWARD AVENUE
Provider Second Line Business Mailing Address:
SUITE 507
Provider Business Mailing Address City Name:
PONTIAC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48341-2935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-335-8170
Provider Business Mailing Address Fax Number:
248-858-3920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44555 WOODWARD AVENUE
Provider Second Line Business Practice Location Address:
SUITE 507
Provider Business Practice Location Address City Name:
PONTIAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48341-2935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-335-8170
Provider Business Practice Location Address Fax Number:
248-858-3920
Provider Enumeration Date:
11/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BAGNASCO
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-335-8170

Provider Taxonomy Codes

  • Taxonomy code: 207RI0011X , with the licence number:  FB034436 , 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: 104150113 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: FB034436 . This is a "LICENSE STATE OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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