1891712493 NPI number — NORTHRIDGE FAMILY PRACTICE LLC

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 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: 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" .
  • 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" .

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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