1548244916 NPI number — BRIAN J MCCOMB DO PLLC

Table of content: (NPI 1548244916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548244916 NPI number — BRIAN J MCCOMB DO PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIAN J MCCOMB DO PLLC
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:
1548244916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 E PARKDALE AVE
Provider Second Line Business Mailing Address:
SUITE #1
Provider Business Mailing Address City Name:
MANISTEE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49660-9776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-723-9301
Provider Business Mailing Address Fax Number:
231-723-1592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 E PARKDALE AVE
Provider Second Line Business Practice Location Address:
SUITE #1
Provider Business Practice Location Address City Name:
MANISTEE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49660-9776
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-723-9301
Provider Business Practice Location Address Fax Number:
231-723-1592
Provider Enumeration Date:
11/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MCCOMB
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
JAY
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
231-723-9301

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  5101012971 , 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: 7885122 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0855110425 . This is a "BLUE CROSS BLUE SHIELD MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00093145 . This is a "PALMETTO GBA RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4566803 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 900018330 . This is a "PRIORITY HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 760743986100 . This is a "COMMUNITY CHOICE" identifier . This identifiers is of the category "OTHER".




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