1790830966 NPI number — BARRY-EATON DISTRICT HEALTH DEPARTMENT

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 1790830966 NPI number — BARRY-EATON DISTRICT HEALTH DEPARTMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BARRY-EATON DISTRICT HEALTH DEPARTMENT
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:
1790830966
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1033 HEALTHCARE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48813-1058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-541-2673
Provider Business Mailing Address Fax Number:
517-543-2656

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 W WOODLAWN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HASTINGS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49058-1035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-541-2673
Provider Business Practice Location Address Fax Number:
517-543-2656
Provider Enumeration Date:
01/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WINGATE
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
E
Authorized Official Title or Position:
FINANCE OFFICER
Authorized Official Telephone Number:
517-541-2673

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5100027 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00297302 . This is a "RR RETIREMENT MASS IMMUNI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1845717 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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