1285672691 NPI number — DR. LEO MARANON MADARANG MD

Table of content: DR. LEO MARANON MADARANG MD (NPI 1285672691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285672691 NPI number — DR. LEO MARANON MADARANG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADARANG
Provider First Name:
LEO
Provider Middle Name:
MARANON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1285672691
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
820 BOUTELL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND BLANC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48439-1943
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-210-7072
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 BEECHER RD.
Provider Second Line Business Practice Location Address:
STE 02
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48532-3685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-342-5500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2006

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: 208600000X , with the licence number:  35518 , 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: 2097957 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0250315 . This is a "BLUECARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0250315 . This is a "BLUE CROSS BLUE SHIELD OF" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 382817349 . This is a "EMPLOYER ID#" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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