1902870918 NPI number — MARION G WENDT NP

Table of content: MARION G WENDT NP (NPI 1902870918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902870918 NPI number — MARION G WENDT NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WENDT
Provider First Name:
MARION
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1902870918
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MICHIGAN ST NE
Provider Second Line Business Mailing Address:
MC845
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503-2560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7751 BYRON CENTER AVE SW
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BYRON CENTER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49315-8001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-267-7668
Provider Business Practice Location Address Fax Number:
616-356-1941
Provider Enumeration Date:
02/15/2006

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: 363L00000X , with the licence number:  4704223755 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , with the licence number: 4704223755 , 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: 4780026 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4780035 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4780062 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4780071 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4780053 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5008705490 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4780044 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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