1255312302 NPI number — DR. MATTHEW WARREN SEVENSMA

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 1255312302 NPI number — DR. MATTHEW WARREN SEVENSMA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEVENSMA
Provider First Name:
MATTHEW
Provider Middle Name:
WARREN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1255312302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5900 BYRON CENTER AVE SW
Provider Second Line Business Mailing Address:
MEDICAL ADMINISTRATION
Provider Business Mailing Address City Name:
WYOMING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49519-9606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-252-3243
Provider Business Mailing Address Fax Number:
616-252-0260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2122 HEALTH DR SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WYOMING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49519-9698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-252-5950
Provider Business Practice Location Address Fax Number:
616-252-5956
Provider Enumeration Date:
11/07/2005

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: 207RC0000X , with the licence number:  5101014388 , 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: 5101014388 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00245050 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: MS014388 . This is a "BCBSM PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4729758 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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