1063827152 NPI number — JONATHAN M HORBAL DO PLC

Table of content: (NPI 1063827152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063827152 NPI number — JONATHAN M HORBAL DO PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JONATHAN M HORBAL DO PLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MIDLAND ALLERGY CLINIC
Provider Other Organization Name Type Code:
3
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:
1063827152
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 W WACKERLY ST
Provider Second Line Business Mailing Address:
STE 2675
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48640-4722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-631-1010
Provider Business Mailing Address Fax Number:
989-839-8800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 W WACKERLY ST
Provider Second Line Business Practice Location Address:
STE 2675
Provider Business Practice Location Address City Name:
MIDLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48640-4722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-631-1010
Provider Business Practice Location Address Fax Number:
989-839-8800
Provider Enumeration Date:
06/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HORBAL
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
989-631-1010

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  5101018381 , 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: 5560079 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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