1679553952 NPI number — THERESA MAYHARTLE DO

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 1679553952 NPI number — THERESA MAYHARTLE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAYHARTLE
Provider First Name:
THERESA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1679553952
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 S BALLENGER HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48532-3638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-342-1000
Provider Business Mailing Address Fax Number:
810-342-1590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12805 ESCANABA DR
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
DEWITT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48820-8628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-367-5520
Provider Business Practice Location Address Fax Number:
517-367-5521
Provider Enumeration Date:
01/20/2006

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: 207V00000X , with the licence number:  5101011364 , 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: 252503 . This is a "HEALTH ADVANTAGE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 01795 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0700186 . This is a "PHYSICIANS HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 252503 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1651913484 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4154702 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: G10710 . This is a "HEALTH NET FEDERAL SERVIC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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