1700824612 NPI number — DR. PANKAJ JANDWANI M.D.

Table of content: DR. PANKAJ JANDWANI M.D. (NPI 1700824612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700824612 NPI number — DR. PANKAJ JANDWANI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JANDWANI
Provider First Name:
PANKAJ
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1700824612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 173
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALMA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48801-0173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-463-5740
Provider Business Mailing Address Fax Number:
888-346-7607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 E WARWICK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALMA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48801-1014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-463-5740
Provider Business Practice Location Address Fax Number:
888-346-7607
Provider Enumeration Date:
06/03/2006

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: 174400000X , with the licence number:  4301070136 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 4301070136 , 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: 1102911791 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1012007 . This is a "MCLAREN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P109253 . This is a "BLUECARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4639991 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4270247 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4565225 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4671470 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1105910131 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1012005 . This is a "MCLAREN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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