1255802559 NPI number — IHA OLMA PRIMARY CARE RISK LLC

Table of content: (NPI 1255802559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255802559 NPI number — IHA OLMA PRIMARY CARE RISK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IHA OLMA PRIMARY CARE RISK LLC
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:
IHA LIVONIA PRIMARY CARE
Provider Other Organization Name Type Code:
3
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:
1255802559
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 FRANK LLOYD WRIGHT DR STE J2000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48105-9484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-747-6766
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19000 ST. JOE'S PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LIVONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48152-1079
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-213-3685
Provider Business Practice Location Address Fax Number:
734-213-3686
Provider Enumeration Date:
12/12/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ELLIOTT
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
734-327-0872

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)