1477680015 NPI number — PAUL W LANCZKI PC

Table of content: (NPI 1477680015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477680015 NPI number — PAUL W LANCZKI PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAUL W LANCZKI 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:
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:
1477680015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1136 COUNTRY CLUB RD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
ADRIAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49221-8208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-265-6055
Provider Business Mailing Address Fax Number:
517-265-6115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1136 COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
ADRIAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49221-8208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-265-6055
Provider Business Practice Location Address Fax Number:
517-265-6115
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MUCK
Authorized Official First Name:
CONSTANCE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
517-265-6055

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901002974 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 4901004286 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4639178-86 . This is a "MEDICAID DISPENSING" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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