1346425568 NPI number — MARIO N CORACI PC

Table of content: (NPI 1346425568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346425568 NPI number — MARIO N CORACI PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIO N CORACI 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:
1346425568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16700 21 MILE RD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
MACOMB
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48044-4887
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16700 21 MILE RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
MACOMB
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48044-4887
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-263-8181
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CORACI
Authorized Official First Name:
MARIO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
586-263-8181

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  MC0001096 , 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: P45316 . This is a "BLUE CARENETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2125505 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480002350 . This is a "TRAVELERS MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: T34328 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104566 . This is a "PRIORITY HEALTH HMO/PPO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1233580002 . This is a "WELLNESS HEALTH PLANS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 17058 . This is a "M-CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 485505096 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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