1912068305 NPI number — MR. MATTHEW BRANDOW AUDIOLOGIST

Table of content: MR. MATTHEW BRANDOW AUDIOLOGIST (NPI 1912068305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912068305 NPI number — MR. MATTHEW BRANDOW AUDIOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRANDOW
Provider First Name:
MATTHEW
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
AUDIOLOGIST
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:
1912068305
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 260
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ISHPEMING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49849-0260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-475-7422
Provider Business Mailing Address Fax Number:
906-486-6898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MALTON ST
Provider Second Line Business Practice Location Address:
STE 7
Provider Business Practice Location Address City Name:
NEGAUNEE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49866-2001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-475-7422
Provider Business Practice Location Address Fax Number:
906-486-6898
Provider Enumeration Date:
12/12/2006

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: 174400000X , with the licence number:  1601000055 , 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: P00110878 . This is a "RRMEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 540E210323 . This is a "BCBS LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 405176011 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 904543700 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 640E210300 . This is a "BCBS LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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