1790894988 NPI number — WEST BRANCH PULMONARY CLINIC PC

Table of content: (NPI 1790894988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790894988 NPI number — WEST BRANCH PULMONARY CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST BRANCH PULMONARY CLINIC 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:
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:
1790894988
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
780 N GAVORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STERLING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48659-9703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-654-2168
Provider Business Mailing Address Fax Number:
989-654-2825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
780 N GAVORD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STERLING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48659-9703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-654-2168
Provider Business Practice Location Address Fax Number:
989-654-2825
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HERRICK
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
INSURANCE BILLER
Authorized Official Telephone Number:
810-564-9270

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: TM0009037 , 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: 1007603 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 115651012 . This is a "BLUE CROSS BLUE SHIELD M" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4261168 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4509887 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1007603 . This is a "MCLAREN HEALTH ADVANTAGE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 122278 . This is a "PREFERRED CHOICE PPO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110216075 . This is a "RR MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 115651012 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1679561443 . This is a "NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 54 0 F5 10350 . This is a "BLUE CROSS BLUE SHIELD DM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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