1760404891 NPI number — GRAND TRAVERSE RADIOLOGISTS PC

Table of content: (NPI 1760404891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760404891 NPI number — GRAND TRAVERSE RADIOLOGISTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND TRAVERSE RADIOLOGISTS PC
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:
1760404891
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30516
Provider Second Line Business Mailing Address:
DEPT. 9516
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48909-8016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-475-6112
Provider Business Mailing Address Fax Number:
423-826-1286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1105 SIXTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49684-2345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-935-0497
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LUNG
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
231-935-0497

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 134232100 . This is a "US DEPT. OF LABOR" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 27837 . This is a "COMMUNITY CHOICE MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 53556A . This is a "HEALTH ALLIANCE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 008081 . This is a "MIDWEST HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: XX00308 . This is a "HEALTHPLUS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104756 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 12088500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10399 . This is a "M-CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104756 . This is a "PREFERRED CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CA3471 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: N16010 . This is a "NORTHMED HMO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0B87605 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 280047 . This is a "FEDERAL BLACK LUNG" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4055 . This is a "PRIORITY HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 803002 . This is a "COMMUNITY CARE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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