1760546410 NPI number — STANLEY A. MATERKA, DO PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760546410 NPI number — STANLEY A. MATERKA, DO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STANLEY A. MATERKA, DO 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:
1760546410
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8836
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49518-8836
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-898-7139
Provider Business Mailing Address Fax Number:
616-975-9824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 HARRINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT CLEMENS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48043-2920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-493-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MATERKA
Authorized Official First Name:
STANLEY
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
586-493-8000

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0155000555 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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