1376645580 NPI number — MICHAEL J SUTTON DO

Table of content: MICHAEL J SUTTON DO (NPI 1376645580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376645580 NPI number — MICHAEL J SUTTON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUTTON
Provider First Name:
MICHAEL
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1376645580
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3239
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29502-3239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-841-3517
Provider Business Mailing Address Fax Number:
843-841-3519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 N 8TH AVE
Provider Second Line Business Practice Location Address:
SUITE 1B
Provider Business Practice Location Address City Name:
DILLON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29536-2549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-487-1588
Provider Business Practice Location Address Fax Number:
843-487-1597
Provider Enumeration Date:
09/01/2006

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: 207XX0005X , with the licence number:  MS007501 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: 457 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 064 . This is a "BCBS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 004578 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 062 . This is a "BLUECHOICE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 207327 . This is a "MEDCOST" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 4066223 . This is a "AETNA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 5909178 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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