1417924200 NPI number — JOHN H TRASK PH.D.

Table of content: JOHN H TRASK PH.D. (NPI 1417924200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417924200 NPI number — JOHN H TRASK PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRASK
Provider First Name:
JOHN
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.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:
1417924200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 E BIG BEAVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48083-1208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-689-4600
Provider Business Mailing Address Fax Number:
248-519-1201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 E BIG BEAVER RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48083-1432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-689-4600
Provider Business Practice Location Address Fax Number:
248-519-1201
Provider Enumeration Date:
03/01/2006

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: 103TC0700X , with the licence number:  6301007751 , 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: 1164693362 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 68-0-F3-2859-0 . This is a "BLUE CROSS BLUE SHIELD MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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