1023161064 NPI number — RONALD B. PENFIELD MSW

Table of content: RONALD B. PENFIELD MSW (NPI 1023161064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023161064 NPI number — RONALD B. PENFIELD MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENFIELD
Provider First Name:
RONALD
Provider Middle Name:
B.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW
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:
1023161064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
913 W HOLMES RD
Provider Second Line Business Mailing Address:
STE 143
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48910-0435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-853-2992
Provider Business Mailing Address Fax Number:
517-853-2993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4990 NORTHWIND DR
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48823-5090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-853-2992
Provider Business Practice Location Address Fax Number:
517-853-2993
Provider Enumeration Date:
01/22/2007

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: 104100000X , with the licence number:  6801004048 , 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: 8008940080 . This is a "INDIVIDUAL BCBS PIN #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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