1063638682 NPI number — DR. MICHAEL T COURIS MD

Table of content: DR. MICHAEL T COURIS MD (NPI 1063638682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063638682 NPI number — DR. MICHAEL T COURIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COURIS
Provider First Name:
MICHAEL
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1063638682
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3969 4TH AVE
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92103-3165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-291-6191
Provider Business Mailing Address Fax Number:
619-291-0049

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3969 4TH AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-3165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-291-6191
Provider Business Practice Location Address Fax Number:
619-291-0049
Provider Enumeration Date:
04/18/2007

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: 207W00000X , with the licence number:  A53265 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00A532651 . This is a "MEDICARE-SPECTRUM" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 180046485 . This is a "PALMETTO GBA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: A53265B . This is a "MEDICARE PIN-SPECTRUM" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A532651 . This is a "MEDI-CAL SPECTRUM" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 180046485 . This is a "RR MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: P00353462 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A532650 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 522450085 . This is a "TAX ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A532650 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 4401850001 . This is a "DMERC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 5224500859210300 . This is a "CHAMPUS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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