1467631804 NPI number — SEMINOLE SHORES INTERNAL MEDICINE PC

Table of content: (NPI 1467631804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467631804 NPI number — SEMINOLE SHORES INTERNAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEMINOLE SHORES INTERNAL MEDICINE 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:
1467631804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
433 SEMINOLE RD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
MUSKEGON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49444-3743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-739-2192
Provider Business Mailing Address Fax Number:
231-739-2343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
433 SEMINOLE RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
MUSKEGON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49444-3743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-739-2192
Provider Business Practice Location Address Fax Number:
231-739-2343
Provider Enumeration Date:
11/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OGAS
Authorized Official First Name:
CARL
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
231-739-2192

Provider Taxonomy Codes

  • Taxonomy code: 207RS0010X , with the licence number:  4301062711 , 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: 1106110251 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4559980 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com