1992791453 NPI number — WILLIAM J DEMOTS MD

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 1992791453 NPI number — WILLIAM J DEMOTS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMOTS
Provider First Name:
WILLIAM
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1992791453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 KIMOLE LN
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
ADRIAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49221-1478
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-263-5655
Provider Business Mailing Address Fax Number:
517-263-8012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8765 LEWIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPERANCE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48182-9583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-847-3802
Provider Business Practice Location Address Fax Number:
734-850-0520
Provider Enumeration Date:
09/21/2005

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: 207Q00000X , with the licence number:  4301035215 , 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: 4783547 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03634 . This is a "PARAMOUNT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 396443925-001 . This is a "MMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4220274 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0804641971 . This is a "BCBS MI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000387441 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 113277 . This is a "CARECHOICES/PREFERRED CHO" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00254442 . This is a "RRMC" identifier . This identifiers is of the category "OTHER".
  • Identifier: E86031 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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