1417905613 NPI number — GREATER LANSING SURGEONS, P.C.

Table of content: (NPI 1417905613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417905613 NPI number — GREATER LANSING SURGEONS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREATER LANSING SURGEONS, P.C.
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:
6
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:
1417905613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2815 S PENNSYLVANIA AVE
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48910-3496
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-487-8255
Provider Business Mailing Address Fax Number:
517-487-2059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2815 S PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48910-3496
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-487-8255
Provider Business Practice Location Address Fax Number:
517-487-2059
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MERCER
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
517-487-8255

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  SS013541 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: JD014681 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: CM005070 , 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: CA 3383 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4404799 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5330326 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 53311215 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4748047 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5331175 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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