1285800268 NPI number — DIANNE KAY TRUDELL, MD

Table of content: (NPI 1285800268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285800268 NPI number — DIANNE KAY TRUDELL, MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIANNE KAY TRUDELL, 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:
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:
1285800268
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5085 W BRISTOL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48507-2922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-230-2400
Provider Business Mailing Address Fax Number:
810-230-1616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5085 W BRISTOL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48507-2922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-230-2400
Provider Business Practice Location Address Fax Number:
810-230-1616
Provider Enumeration Date:
04/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SOPKO
Authorized Official First Name:
KRISTEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
810-230-1790

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  DT048800 , 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: 1102511962 . This is a "BCBS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1826025002 . This is a "GENESEE HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1996631 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4092874 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C1542 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: E38039 . This is a "UPIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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