1093894164 NPI number — LARA R CLARY-LANTIS D.O.

Table of content: LARA R CLARY-LANTIS D.O. (NPI 1093894164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093894164 NPI number — LARA R CLARY-LANTIS D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARY-LANTIS
Provider First Name:
LARA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

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:
1093894164
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 FRANK LLOYD WRIGHT DR
Provider Second Line Business Mailing Address:
PO BOX 0446 - LOBBY J
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48105-9484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-747-6766
Provider Business Mailing Address Fax Number:
734-222-3100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5301 E HURON RIVER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YPSILANTI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48197-1051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-712-8676
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2006

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: 207QH0002X , with the licence number:  5101018066 , 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: 000000344854 . This is a "BLUE CROSS/SHIELD PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64087901 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2509968 . This is a "OHIO MEDICAID PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P00168867 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: P00734129 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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