1942584941 NPI number — HEIDI FITE PA-C

Table of content: HEIDI FITE PA-C (NPI 1942584941)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942584941 NPI number — HEIDI FITE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITE
Provider First Name:
HEIDI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SZERLONG
Provider Other First Name:
HEIDI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1942584941
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11293 N M 37
Provider Second Line Business Mailing Address:
STE. A
Provider Business Mailing Address City Name:
BUCKLEY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49620-9593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-269-4185
Provider Business Mailing Address Fax Number:
231-269-4461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11293 N M 37
Provider Second Line Business Practice Location Address:
STE. A
Provider Business Practice Location Address City Name:
BUCKLEY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49620-9593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-269-4185
Provider Business Practice Location Address Fax Number:
231-269-4461
Provider Enumeration Date:
10/10/2011

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: 363A00000X , with the licence number:  6274 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 5601007246 , 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: 1343PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003121146A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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