1992831960 NPI number — CHARLES E JESSUP DO

Table of content: CHARLES E JESSUP DO (NPI 1992831960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992831960 NPI number — CHARLES E JESSUP DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JESSUP
Provider First Name:
CHARLES
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1992831960
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1003 WOODSIDE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ESSEXVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48732-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-892-7722
Provider Business Mailing Address Fax Number:
989-892-7455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 N WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48756-5117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-873-3352
Provider Business Practice Location Address Fax Number:
989-873-3949
Provider Enumeration Date:
02/26/2007

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: 208D00000X , with the licence number:  5101005335 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 5101005335 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 233873 . This is a "RIVERBEND" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 010F510190 . This is a "BUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0156150214 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080Z910290 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4303974 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2624597 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 383369085 . This is a "COMMERCIAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4279897 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010Z900580 . This is a "BCBS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 233866 . This is a "RIVERBEND" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 382821013 . This is a "COMMERCIAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 383369085100 . This is a "COMMUNITY CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0Z90058 . This is a "BCBS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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