1669096111 NPI number — JACOB ALEXANDER MARTIN NOVACK DO

Table of content: JACOB ALEXANDER MARTIN NOVACK DO (NPI 1669096111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669096111 NPI number — JACOB ALEXANDER MARTIN NOVACK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOVACK
Provider First Name:
JACOB
Provider Middle Name:
ALEXANDER MARTIN
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:
1669096111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26460 BELANGER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48066-3162
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-216-2615
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27351 DEQUINDRE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48071-3487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-967-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2020

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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