NPI |
1962438556 |
The first name of the provider, if the provider
is an individual. |
Entity Type Code |
2 |
The middle name of the provider, if the provider
is an individual. |
Employer Identification Number EIN |
|
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Organization Name Legal Business Name |
KALKASKA FAMILY PRACTICE PC |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
Provider First Line Business Practice Location Address |
419 S CORAL ST |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address City Name |
KALKASKA |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
MI |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Postal Code |
496462500 |
The telephone number associated with the location address of the provider being identified. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
2312587777 |
The telephone number associated with the location address of the provider being identified. |
Provider Enumeration Date |
6/24/2006 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
1/5/2012 |
The date that a record was last updated or changed. |
Authorized Official Last Name |
BIRGY |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
Authorized Official First Name |
DOREEN |
The first name of the authorized official. |
Authorized Official Middle Name |
M |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Authorized Official Title or Position |
PRACTICE MGR |
|
Authorized Official Telephone Number |
2312587570 |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
Healthcare Provider Taxonomy Code 1 |
207Q00000X |
|
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Other Provider Identifier 1 |
080Z56005 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Other Provider Identifier Type Code 1 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Other Provider Identifier State 1 |
MI |
|
Other Provider Identifier Issuer 1 |
BCBS |
|
Other Provider Identifier 2 |
1962438556 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Other Provider Identifier Type Code 2 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Other Provider Identifier State 2 |
MI |
|
Is Organization Subpart |
N |
|
Healthcare Provider Taxonomy Group 1 |
193400000X SINGLE SPECIALTY GROUP |
|