1992184964 NPI number — MS. LISA M DREW PROVIDER

Table of content: MS. LISA M DREW PROVIDER (NPI 1992184964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992184964 NPI number — MS. LISA M DREW PROVIDER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DREW
Provider First Name:
LISA
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PROVIDER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PAYNE
Provider Other First Name:
LISA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992184964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 ELTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ECORSE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48229-1769
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-756-6679
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 ELTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ECORSE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48229-1769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-409-5675
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2015

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: 172V00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , 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: 5157600 . This is a "SEMI INDEPENDENT ROOMING HOUSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5157600 . This is a "HOME CHORE SERVICE WORKER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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