1831388537 NPI number — BAYSIDE ALLERGY, P.C.

Table of content: (NPI 1831388537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831388537 NPI number — BAYSIDE ALLERGY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAYSIDE ALLERGY, P.C.
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:
1831388537
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
447 MUNSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49686-3084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-929-9090
Provider Business Mailing Address Fax Number:
231-929-9092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
447 MUNSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49686-3084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-929-9090
Provider Business Practice Location Address Fax Number:
231-929-9092
Provider Enumeration Date:
10/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCCLELLAN III
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
STEELE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
231-929-9090

Provider Taxonomy Codes

  • Taxonomy code: 207KA0200X , with the licence number:  JM073559 , 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: 1124089073 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1831388537 . This is a "BAYSIDE ALLERGY PC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1124089073 . This is a "JAMES S MCCLELLAN III MD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1831388537 . This is a "R/R MEDICARE NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 030B812180 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1831388537 . This is a "GROUP NPI NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: DN0970 . This is a "R/R MEDICARE GRP PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1124089073 . This is a "INDIVIDUAL NPI NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: G38913 . This is a "PRIORIITY NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0P50390 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00603999 . This is a "R/R MEDICARE PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1124089073 . This is a "R/R/MEDICARE MEMBER NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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