1548668999 NPI number — FMG MERIDIAN STREET MICHIGAN LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548668999 NPI number — FMG MERIDIAN STREET MICHIGAN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FMG MERIDIAN STREET MICHIGAN LLC
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:
6
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:
1548668999
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1011 MERIDIAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAULT SAINTE MARIE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49783-2650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-635-1518
Provider Business Mailing Address Fax Number:
906-635-1436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 MERIDIAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAULT SAINTE MARIE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49783-2650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-635-1518
Provider Business Practice Location Address Fax Number:
906-635-1436
Provider Enumeration Date:
12/17/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KEATING
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
414-908-8058

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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