1386704781 NPI number — LUIS C. GAGO M.D.

Table of content: LUIS C. GAGO M.D. (NPI 1386704781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386704781 NPI number — LUIS C. GAGO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAGO
Provider First Name:
LUIS
Provider Middle Name:
C.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1386704781
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 W NORTH ST STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49202-3196
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-852-8463
Provider Business Mailing Address Fax Number:
571-817-0144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2350 E STADIUM BLVD
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48104-4889
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-852-8463
Provider Business Practice Location Address Fax Number:
734-994-6283
Provider Enumeration Date:
12/08/2006

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: 207W00000X , with the licence number:  4301076027 , 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: 467549710 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: LG076027 . This is a "COMMERCIAL-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 180H149970 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: LG076027 . This is a "CHAMPUS-CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1386704781 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180H262240 . This is a "BLUE CROSS-BLUE CROSS" identifier . This identifiers is of the category "OTHER".




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