1790868024 NPI number — CHARLES EDWARD HANNA

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 1790868024 NPI number — CHARLES EDWARD HANNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES EDWARD HANNA
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:
1790868024
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:
1504 HARCREST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-631-2900
Provider Business Mailing Address Fax Number:
989-631-2915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1504 HARCREST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-631-2900
Provider Business Practice Location Address Fax Number:
989-631-2915
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HANNA
Authorized Official First Name:
MARLENE
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
989-631-2900

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  08577 , 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: 4004330 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com