1760455513 NPI number — SARAH BETHANY MCDADE MD

Table of content: SARAH BETHANY MCDADE MD (NPI 1760455513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760455513 NPI number — SARAH BETHANY MCDADE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDADE
Provider First Name:
SARAH
Provider Middle Name:
BETHANY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1760455513
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1405 BALMORAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48203-1442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-622-5662
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27209 LAHSER RD
Provider Second Line Business Practice Location Address:
SUITE 221
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48034-8401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-569-2000
Provider Business Practice Location Address Fax Number:
248-569-2008
Provider Enumeration Date:
02/10/2006

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: 2081S0010X , with the licence number:  4301074905 , 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: 0P50670 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4933813 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4818400-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4925830 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4933804 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 134931 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 157928 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0636250 . This is a "BCBSM PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 421720541 . This is a "TRICARE STANDARD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1951791 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7526086 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1760455513 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 612901000 . This is a "DOL / WORKERS COMP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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