1679767222 NPI number — KATE MERYL SUPIANOSKI PA

Table of content: KATE MERYL SUPIANOSKI PA (NPI 1679767222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679767222 NPI number — KATE MERYL SUPIANOSKI PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUPIANOSKI
Provider First Name:
KATE
Provider Middle Name:
MERYL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHARPHORN
Provider Other First Name:
KATE
Provider Other Middle Name:
MERYL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679767222
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
804 SERVICE RD
Provider Second Line Business Mailing Address:
A201
Provider Business Mailing Address City Name:
EAST LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48824-7015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-884-2976
Provider Business Mailing Address Fax Number:
517-432-3928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4660 S HAGADORN RD
Provider Second Line Business Practice Location Address:
STE 420
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-884-6100
Provider Business Practice Location Address Fax Number:
517-884-6233
Provider Enumeration Date:
08/28/2007

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: 363AM0700X , with the licence number:  5601005114 , 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: 1679767222 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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