1730300377 NPI number — JAMES P. SERINO, O.D. P.C.

Table of content: (NPI 1730300377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730300377 NPI number — JAMES P. SERINO, O.D. P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAMES P. SERINO, O.D. P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1730300377
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
306 W WASHINGTON AVE
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49201-2169
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-783-6928
Provider Business Mailing Address Fax Number:
517-784-9633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
306 W WASHINGTON AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49201-2169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-783-6928
Provider Business Practice Location Address Fax Number:
517-784-9633
Provider Enumeration Date:
05/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SERINO
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
517-783-6928

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901003057 , 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: 5448465 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 410020815 . This is a "PALMETTO GBA RR MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 200000004902 . This is a "PHP OF SOUTH MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 900C812040 . This is a "BCBS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com