1275611246 NPI number — WILLIAM ROY SHOULDICE OD

Table of content: WILLIAM ROY SHOULDICE OD (NPI 1275611246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275611246 NPI number — WILLIAM ROY SHOULDICE OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOULDICE
Provider First Name:
WILLIAM
Provider Middle Name:
ROY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1275611246
Entity Type Code:
Individual
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:
PO BOX 1665
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAYLORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49734-5665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-732-6455
Provider Business Mailing Address Fax Number:
989-732-1102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 W NORTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAYLORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49735-1525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-732-6455
Provider Business Practice Location Address Fax Number:
989-732-1102
Provider Enumeration Date:
11/01/2006

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: 152W00000X , with the licence number:  4901003939 , 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: 0585020001 . This is a "ADMINASTAR" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 410037242 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 900A665060 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0M69410 . This is a "MEDICARE PLUS BLUE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3493121 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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