1073568408 NPI number — DELMER JOHN DEHART

Table of content: (NPI 1073568408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073568408 NPI number — DELMER JOHN DEHART

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELMER JOHN DEHART
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:
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:
1073568408
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3061 CHRISTY WAY
Provider Second Line Business Mailing Address:
C/O PRO MED BILLING
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48603-2267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-791-2455
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2135 LONE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREELAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48623-8878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-860-4735
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEHART
Authorized Official First Name:
DEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
989-860-4735

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  4301406760 , 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: 4174151 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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