1487648374 NPI number — PINE TREES MEDICAL OFFICE PC

Table of content: (NPI 1487648374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487648374 NPI number — PINE TREES MEDICAL OFFICE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE TREES MEDICAL OFFICE 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:
1487648374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11610 WALDRON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEROME
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49249-9637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-688-4842
Provider Business Mailing Address Fax Number:
517-688-4842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11610 WALDRON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEROME
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49249-9637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-688-4842
Provider Business Practice Location Address Fax Number:
517-688-4842
Provider Enumeration Date:
09/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BOYER
Authorized Official First Name:
ROY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
517-688-4842

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301028315 , 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: P41335 . This is a "BLUE CARE NETWORK HMO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1 106914130 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4462854 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com