Basic Information
| Provider Information | |||||||||
| NPI: | 1093811515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARESCA | ||||||||
| FirstName: | CARLOTTA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1447 N HARRISON ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486024727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895832833 | ||||||||
| FaxNumber: | 9895831440 | ||||||||
| Practice Location | |||||||||
| Address1: | 5400 MACKINAW RD | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486049515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895835060 | ||||||||
| FaxNumber: | 9895835046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 06/13/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | CM042961 | MI | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 020042476 | 01 | MI | RAILROAD MEDICARE # | OTHER | 1009436 | 01 | MI | MCLAREN HEALTH PLAN # | OTHER | 104415 | 01 | MI | GREAT LAKES HEALTH PLAN | OTHER | C3006 | 01 | MI | M-CARE PROVIDER NUMBER | OTHER | 101590592 | 05 | MI | MEDICAID | 0207311781 | 01 | MI | BCBS PROVIDER ID | OTHER | 382684672 | 01 | MI | TAX ID | OTHER | 0207310861 | 01 | MI | HEALTHPLUS PROVIDER # | OTHER |