1225117492 NPI number — DR. INGRID JULIE YEO CHUA-MANALO MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225117492 NPI number — DR. INGRID JULIE YEO CHUA-MANALO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHUA-MANALO
Provider First Name:
INGRID JULIE
Provider Middle Name:
YEO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1225117492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29275 NORTHWESTERN HWY.
Provider Second Line Business Mailing Address:
STE. 100
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48034-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-784-3667
Provider Business Mailing Address Fax Number:
248-869-3982

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46325 W. TWELVE MILE RD.
Provider Second Line Business Practice Location Address:
STE. 100
Provider Business Practice Location Address City Name:
NOVI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48377-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-784-3667
Provider Business Practice Location Address Fax Number:
248-869-3982
Provider Enumeration Date:
11/06/2006

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: 208VP0000X , with the licence number:  4301064281 , 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: 4607165 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0007272058 . This is a "AETNA PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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