1891712493 NPI number — NORTHRIDGE FAMILY PRACTICE LLC

Table of content: (NPI 1891712493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891712493 NPI number — NORTHRIDGE FAMILY PRACTICE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHRIDGE FAMILY PRACTICE LLC
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:
1891712493
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 279
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HALE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48739-0279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-728-6000
Provider Business Mailing Address Fax Number:
989-728-6003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3190 NORTHRIDGE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HALE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48739-9276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-728-6000
Provider Business Practice Location Address Fax Number:
989-728-6003
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PROVOAST
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
KAYE
Authorized Official Title or Position:
MANAGING OFFICER
Authorized Official Telephone Number:
989-728-6000

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301061417 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 4704173663 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: 4704148660 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 4704245250 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 4704283185 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1017859 . This is a "MCLAREN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 105230710 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: BW148660 . This is a "BETH WEAVER LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: MA061417 . This is a "MOHAMED ALI" identifier . This identifiers is of the category "OTHER".
  • Identifier: RAILROAD MEDICARE . This is a "P00261196" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4704283185 . This is a "LINDSEY LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104289418 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105235126 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: OC51020 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1017858 . This is a "MCLAREN DEB PROVOAST" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: DP173663 . This is a "DEBBIE PROVOAST LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: DD9334 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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