1245228568 NPI number — LINO SEVANDAL DIAL JR. DO

Table of content: LINO SEVANDAL DIAL JR. DO (NPI 1245228568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245228568 NPI number — LINO SEVANDAL DIAL JR. DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIAL
Provider First Name:
LINO
Provider Middle Name:
SEVANDAL
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
DO
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:
1245228568
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5511 WEST U.S. HIGHWAY 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUDINGTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-843-1553
Provider Business Mailing Address Fax Number:
231-845-5515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 S. MISSION STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT. PLEASANT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-773-9700
Provider Business Practice Location Address Fax Number:
989-779-9701
Provider Enumeration Date:
10/11/2005

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: 207Q00000X , with the licence number:  5101014103 , 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: 0N85680 . This is a "MEDICARE GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1245228568 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 700E310160 . This is a "BCBS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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