1265826655 NPI number — CRAIG N BADE MD

Table of content: (NPI 1265826655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265826655 NPI number — CRAIG N BADE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRAIG N BADE MD
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:
1265826655
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29 W 8TH ST
Provider Second Line Business Mailing Address:
STE 220
Provider Business Mailing Address City Name:
HOLLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49423-3185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-396-1433
Provider Business Mailing Address Fax Number:
616-396-9643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29 W 8TH ST
Provider Second Line Business Practice Location Address:
STE 220
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49423-3185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-396-1433
Provider Business Practice Location Address Fax Number:
616-396-9643
Provider Enumeration Date:
03/24/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HAVERDINK
Authorized Official First Name:
KRISTI
Authorized Official Middle Name:
JOY
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
616-396-1433

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  6301008394 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 4704233966 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 4301039774 , 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: 6301008394 . This is a "STATE LISCENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4301039774 . This is a "STATE LISCENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2109477 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1871743898 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4704233966 . This is a "STATE LISCENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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