1336230788 NPI number — SHIAWASSEE PEDIATRICS PC

Table of content: (NPI 1336230788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336230788 NPI number — SHIAWASSEE PEDIATRICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHIAWASSEE PEDIATRICS PC
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:
1336230788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
802 W KING ST
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
OWOSSO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48867-2100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-729-4848
Provider Business Mailing Address Fax Number:
989-729-4849

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
802 W KING ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
OWOSSO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48867-2100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-729-4848
Provider Business Practice Location Address Fax Number:
989-729-4849
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MUNSON
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
989-729-4848

Provider Taxonomy Codes

  • Taxonomy code: 163WG0000X , with the licence number:  4704113660 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208000000X , with the licence number: 4301029347 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1012477 . This is a "MCLAREN HEALTH PLANS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3507810231 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1200321 . This is a "PHYSICIAN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4924725 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4671219 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0982812 . This is a "HEALTHPLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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