1497806418 NPI number — SUPERIOR WALK-IN CENTER, PC

Table of content: (NPI 1497806418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497806418 NPI number — SUPERIOR WALK-IN CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPERIOR WALK-IN CENTER, 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:
1497806418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1504 SAND POINT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUNISING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49862-1406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-387-4220
Provider Business Mailing Address Fax Number:
906-387-5449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1414 W FAIR AVE
Provider Second Line Business Practice Location Address:
SUITE 134
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-2675
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-226-2233
Provider Business Practice Location Address Fax Number:
906-226-2409
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OLSON
Authorized Official First Name:
KURT
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
906-387-4220

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 080Z210080 . This is a "BLUE CROSS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0800217321 . This is a "BLUE CROSS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3114604 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135602000 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D961305 . This is a "CLIA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 135602000 . This is a "UNITED STATES POST OFFICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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