1699808857 NPI number — PETER J POLVERINI DDS, DMSC

Table of content: PETER J POLVERINI DDS, DMSC (NPI 1699808857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699808857 NPI number — PETER J POLVERINI DDS, DMSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLVERINI
Provider First Name:
PETER
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS, DMSC
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:
1699808857
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5700 SOUTHWYCK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43614-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-288-8325
Provider Business Mailing Address Fax Number:
419-866-5453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 N UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48109-1078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-763-6933
Provider Business Practice Location Address Fax Number:
734-763-5142
Provider Enumeration Date:
03/14/2007

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: 122300000X , with the licence number:  2901016040 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 2901016040 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0106X , with the licence number: 2901016040 , 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: 4504373 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4070694 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 195816845 . This is a "BCBS OF MI MED SURGICAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2667583 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4874042 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: D160400 . This is a "BCBS OF MI DENTAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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