1205930773 NPI number — DR. JOHN WILLIAM DIRCKS M.D.

Table of content: (NPI 1154794683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205930773 NPI number — DR. JOHN WILLIAM DIRCKS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIRCKS
Provider First Name:
JOHN
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1205930773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 JOHN ST
Provider Second Line Business Mailing Address:
BOX 42
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49007-5341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-341-7806
Provider Business Mailing Address Fax Number:
269-341-8743

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 JOHN ST
Provider Second Line Business Practice Location Address:
BOX 74
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49007-5341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-341-8481
Provider Business Practice Location Address Fax Number:
269-341-7781
Provider Enumeration Date:
09/12/2006

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: 207RP1001X , with the licence number:  JD028898 , 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: 290C96034 . This is a "BC/BS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P54696 . This is a "BLUECARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 382356205105 . This is a "COMMUNITY CHOICE OF MICH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 290C913410 . This is a "BCBS GRP PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4830033 . This is a "PHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4991610 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4809116 . This is a "PHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 290390908 . This is a "BCBS IND PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 108097 . This is a "GRT LAKES HLTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4379449 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1386445 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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