1235115460 NPI number — COUNTY OF GENESEE OFFICE OF CONTROLLER

Table of content: (NPI 1235115460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235115460 NPI number — COUNTY OF GENESEE OFFICE OF CONTROLLER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF GENESEE OFFICE OF CONTROLLER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1235115460
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 W 5TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-257-3736
Provider Business Mailing Address Fax Number:
810-257-3785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 W 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-257-3736
Provider Business Practice Location Address Fax Number:
810-257-3785
Provider Enumeration Date:
12/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSELL
Authorized Official First Name:
DANIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
810-257-3707

Provider Taxonomy Codes

  • Taxonomy code: 2083P0901X , with the licence number:  ME0100974 , 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: 2747864 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2125345 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4166893 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4279879 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3283410 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4643653 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4422456 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5101679 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4691230 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4611319 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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