1023003340 NPI number — DR. LISA KIMBERLY LARGO-MARSH PH.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023003340 NPI number — DR. LISA KIMBERLY LARGO-MARSH PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARGO-MARSH
Provider First Name:
LISA
Provider Middle Name:
KIMBERLY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

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:
1023003340
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8799 GULL RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
RICHLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49083-9100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-629-2207
Provider Business Mailing Address Fax Number:
269-629-2207

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8799 GULL ROAD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
RICHLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-629-2207
Provider Business Practice Location Address Fax Number:
269-731-2324
Provider Enumeration Date:
09/13/2005

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: 103TC0700X , with the licence number:  6301008181 , 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: 114812 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1148122 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 680C960810 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 21170586108 . This is a "BEECH STREET CORPORATION" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com