1528004637 NPI number — WESLEY P VON SEGGERN DO

Table of content: WESLEY P VON SEGGERN DO (NPI 1528004637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528004637 NPI number — WESLEY P VON SEGGERN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VON SEGGERN
Provider First Name:
WESLEY
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1528004637
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2332
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49501-2332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-975-1845
Provider Business Mailing Address Fax Number:
616-975-1870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1009 WEST GREEN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HASTINGS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-948-3451
Provider Business Practice Location Address Fax Number:
269-945-3588
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207PE0004X , with the licence number:  5101007600 , 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: P00359242 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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