Basic Information
| Provider Information | |||||||||
| NPI: | 1063412096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAUCEDO | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SPAYDE | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | SUZANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1000 HOUGHTON AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486025303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895836800 | ||||||||
| FaxNumber: | 9895836955 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 HOUGHTON AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486025303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895836800 | ||||||||
| FaxNumber: | 9895836955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2005 | ||||||||
| LastUpdateDate: | 09/21/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 4704182133 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 4512885 | 05 | MI | MEDICAID | 420H310160 | 01 | MI | BC BILLING NUBER | OTHER | 4512885 | 01 | MI | MOLINA | OTHER |