1144479148 NPI number — MICHELLE GORMAS PA

Table of content: MICHELLE GORMAS PA (NPI 1144479148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144479148 NPI number — MICHELLE GORMAS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORMAS
Provider First Name:
MICHELLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1144479148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2422 JOLLY RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKEMOS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48864-3690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-618-9507
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2422 JOLLY RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKEMOS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48864-3690
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-618-9507
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2008

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: 363AM0700X , with the licence number:  5601005380 , 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: 5331355 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 200000055800 . This is a "PHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1144497148 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: C36084082 . This is a "MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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