1821060427 NPI number — JOEL LAWRENCE BEZ DO

Table of content: JOEL LAWRENCE BEZ DO (NPI 1821060427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821060427 NPI number — JOEL LAWRENCE BEZ DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEZ
Provider First Name:
JOEL
Provider Middle Name:
LAWRENCE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1821060427
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
61 COMMERCE AVE SW
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:
49503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-940-0660
Provider Business Mailing Address Fax Number:
616-940-1965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3770 GLENKERRY COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-329-2887
Provider Business Practice Location Address Fax Number:
269-329-2805
Provider Enumeration Date:
02/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  JB011338 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: 5101011338 , 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: 3183460 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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