1528155793 NPI number — BLUEWATER PATHOLOGY PC

Table of content: (NPI 1528155793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528155793 NPI number — BLUEWATER PATHOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUEWATER PATHOLOGY 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:
1528155793
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:
1221 PINE GROVE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT HURON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48060-3511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-989-3270
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1221 PINE GROVE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT HURON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48060-3511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-989-3270
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
810-989-3270

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104673 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0G46251 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1541762 . This is a "UNITED MINEWORKERS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104673 . This is a "PREFERRED CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: XX32047 . This is a "HEALTHPLUS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 027930 . This is a "MIDWEST HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1008856 0001 . This is a "THE WELLNESS PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CH5571 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 34155 . This is a "COMMUNITY CHOICE OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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