1538194923 NPI number — RADIOLOGY ASSOCIATES OF BERRIEN COUNTY PC

Table of content: (NPI 1538194923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538194923 NPI number — RADIOLOGY ASSOCIATES OF BERRIEN COUNTY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RADIOLOGY ASSOCIATES OF BERRIEN COUNTY 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:
1538194923
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
416 STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49085-2297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-982-4104
Provider Business Mailing Address Fax Number:
269-982-4123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1234 NAPIER AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST JOSEPH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-983-8300
Provider Business Practice Location Address Fax Number:
269-983-6965
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEWIND
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
269-982-4104

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300A17602 . This is a "BCBS OF MICHIGAN" identifier . This identifiers is of the category "OTHER".




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