1174511125 NPI number — DR. KENNETH E. VOBACH MD

Table of content: QIANA JORDAN (NPI 1982429577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174511125 NPI number — DR. KENNETH E. VOBACH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VOBACH
Provider First Name:
KENNETH
Provider Middle Name:
E.
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:
1174511125
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 EAST THIRD STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVISON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-412-5437
Provider Business Mailing Address Fax Number:
810-412-5448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 EAST THIRD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVISON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-412-5437
Provider Business Practice Location Address Fax Number:
810-412-5448
Provider Enumeration Date:
10/12/2005

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: 208000000X , with the licence number:  4301075399 , 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: 253067 . This is a "HEALTH ADVANTAGE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 253067 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 350D410030 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4206451 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 350D410030 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: F78643 . This is a "HEATLH NET FEDERAL SERV" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3502505081 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 6824734009 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: F78643 . This is a "HEALTH ALLIANCE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 370018374 . This is a "METRAHEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4475609 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C7478 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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