1457387185 NPI number — GPS OF MICHIGAN INSTITUTIONAL

Table of content: (NPI 1457387185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457387185 NPI number — GPS OF MICHIGAN INSTITUTIONAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GPS OF MICHIGAN INSTITUTIONAL
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:
1457387185
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 KEYSTONE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48911-4041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-882-5515
Provider Business Mailing Address Fax Number:
517-882-6313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 KEYSTONE AVE
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48911-4041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-882-5515
Provider Business Practice Location Address Fax Number:
517-882-6313
Provider Enumeration Date:
06/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GHANNAM
Authorized Official First Name:
FRED
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO OWNER
Authorized Official Telephone Number:
517-882-5515

Provider Taxonomy Codes

  • Taxonomy code: 3336I0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 5301007720 , 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: 2364937 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0097325145 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2364937 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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