1780692400 NPI number — JACKSON COUNTY

Table of content: (NPI 1780692400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780692400 NPI number — JACKSON COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON COUNTY
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:
6
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:
1780692400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1715 LANSING AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49202-2193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-788-4420
Provider Business Mailing Address Fax Number:
517-788-4373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1715 LANSING AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49202-2193
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-788-4420
Provider Business Practice Location Address Fax Number:
517-788-4373
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRAVIS
Authorized Official First Name:
RASHMI
Authorized Official Middle Name:
Authorized Official Title or Position:
HEALTH OFFICER
Authorized Official Telephone Number:
517-768-1658

Provider Taxonomy Codes

  • Taxonomy code: 2083P0901X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 868 . This is a "HEALTH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4300 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 77 279528 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 77 4411612 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 85 . This is a "HEALTH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1339 . This is a "HEALTH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 77 1850332 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 77 4411621 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 895 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23 5100475 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 77 3144336 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1330 . This is a "HEALTH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 77 3363548 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 77 4387900 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: OC8100 . This is a "BLUE CARE NETWORK OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 15 5173678 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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