1093792574 NPI number — DR. MACIEJ SOLAREWICZ MD

Table of content: DR. MACIEJ SOLAREWICZ MD (NPI 1093792574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093792574 NPI number — DR. MACIEJ SOLAREWICZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOLAREWICZ
Provider First Name:
MACIEJ
Provider Middle Name:
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:
1093792574
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3438 BROOKHOLLOW DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49341-9231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-204-4364
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2549 MOMENTUM PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60689-5325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-216-9852
Provider Business Practice Location Address Fax Number:
269-605-0018
Provider Enumeration Date:
12/27/2005

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: 207R00000X , with the licence number:  4301070588 , 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: 4613055 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4812040 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4666101 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4767810 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0F71000 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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