1720301658 NPI number — MS. BRIJITA ARVINDBHAI PATHAK

Table of content: MS. BRIJITA ARVINDBHAI PATHAK (NPI 1720301658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720301658 NPI number — MS. BRIJITA ARVINDBHAI PATHAK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATHAK
Provider First Name:
BRIJITA
Provider Middle Name:
ARVINDBHAI
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
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:
1720301658
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5511 W US HIGHWAY 10
Provider Second Line Business Mailing Address:
SUITE # B
Provider Business Mailing Address City Name:
LUDINGTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49431-2455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-772-7755
Provider Business Mailing Address Fax Number:
989-772-7750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2815 S PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
SUITE # 105B
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48910-3495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-772-7755
Provider Business Practice Location Address Fax Number:
989-772-7750
Provider Enumeration Date:
03/06/2010

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: 225100000X , with the licence number:  5501014589 , 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: 5501014589 . This is a "STATE OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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