1275725533 NPI number — SHAYNA MICHELE BUDRES D.P.T.

Table of content: SHAYNA MICHELE BUDRES D.P.T. (NPI 1275725533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275725533 NPI number — SHAYNA MICHELE BUDRES D.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUDRES
Provider First Name:
SHAYNA
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GARFIELD
Provider Other First Name:
SHAYNA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275725533
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30516
Provider Second Line Business Mailing Address:
DEPT 5300
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-754-7040
Provider Business Mailing Address Fax Number:
616-754-7888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2425 W WASHINGTON ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-225-2325
Provider Business Practice Location Address Fax Number:
616-754-7888
Provider Enumeration Date:
08/10/2007

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: 225100000X , with the licence number:  5510102696 , 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: 30435 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2679020 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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