1104931211 NPI number — GLADWIN FAMILY CARE CENTER P C

Table of content: (NPI 1104931211)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104931211 NPI number — GLADWIN FAMILY CARE CENTER P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLADWIN FAMILY CARE CENTER P C
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:
1104931211
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2007
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:
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:
989-791-1392

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2137 W M61
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLADWIN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-426-9399
Provider Business Practice Location Address Fax Number:
989-246-2257
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHURBAJI
Authorized Official First Name:
HICHAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
989-426-9399

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4276035 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5203202 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5214752 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4989200 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4920566 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7116734 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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