1982824512 NPI number — PSYCHIATRIC PHYSICIANS, PLLC

Table of content: (NPI 1982824512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982824512 NPI number — PSYCHIATRIC PHYSICIANS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHIATRIC PHYSICIANS, PLLC
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:
JAMES P. WIADUCK, M.D.
Provider Other Organization Name Type Code:
3
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:
1982824512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 334
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND HAVEN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-798-8337
Provider Business Mailing Address Fax Number:
231-798-9816

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4461 GRAND HAVEN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUSKEGON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-798-8337
Provider Business Practice Location Address Fax Number:
231-798-9816
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WIADUCK
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
231-798-8337

Provider Taxonomy Codes

  • Taxonomy code: 2084P0015X , with the licence number:  4301066579 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 4301066579 , 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: PTANON10230 . This is a "PTAN ON10230" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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