1124305529 NPI number — ANNE E DAVIDHIZAR NP

Table of content: ANNE E DAVIDHIZAR NP (NPI 1124305529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124305529 NPI number — ANNE E DAVIDHIZAR NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIDHIZAR
Provider First Name:
ANNE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEGEMAN
Provider Other First Name:
ANNE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124305529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3245 HEALTH DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANGER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46530-1380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
721 6TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THREE RIVERS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49093-8302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-273-1418
Provider Business Practice Location Address Fax Number:
269-273-3347
Provider Enumeration Date:
11/14/2011

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: 363L00000X , with the licence number:  4704259063 , 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: 1124305529 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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