1376667634 NPI number — DENNIS C. PACKEY, DO PC

Table of content: (NPI 1376667634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376667634 NPI number — DENNIS C. PACKEY, DO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENNIS C. PACKEY, DO 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:
1376667634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20867 MACK AVE
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
GROSSE POINTE WOODS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48236-1392
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-886-0600
Provider Business Mailing Address Fax Number:
313-886-0612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20867 MACK AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
GROSSE POINTE WOODS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48236-1392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-886-0600
Provider Business Practice Location Address Fax Number:
313-886-0612
Provider Enumeration Date:
03/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PACKEY
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
313-886-0600

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X , with the licence number:  DP006508 , 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: 114836829 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1158213614 . This is a "BCBS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 114836838 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com