1356592943 NPI number — DR. MICHAEL LOUIS SQUIRE MD

Table of content: SABRINA LAVENGOOD LPC (NPI 1679106769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356592943 NPI number — DR. MICHAEL LOUIS SQUIRE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SQUIRE
Provider First Name:
MICHAEL
Provider Middle Name:
LOUIS
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:
1356592943
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2624 RIDGEWAY CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONES
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73049-4971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-297-5302
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2624 RIDGEWAY CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONES
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73049-4971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-297-5302
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/01/2008

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: 2085B0100X , with the licence number:  M-13157 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085B0100X , with the licence number: MD60461265 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: M-13157 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 072452 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: M-13157 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: MD60461265 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: MD60461265 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0385157 . This is a "L&I-SOUTH SOUND RADIOLOGY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0353469 . This is a "L&I-RADIA KING CTY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2044272 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0353470 . This is a "L&I-SWEDISH RADIA EDMONDS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0353472 . This is a "L&I-EVERGREEN RADIA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1356592943 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0353429 . This is a "L&I-RADIA REST OF WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0405139 . This is a "L&I-SEATTLE RADIOLOGY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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