Basic Information
Provider Information | |||||||||
NPI: | 1144390675 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTER FOR FAMILY HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CENTER FOR FAMILY HEALTH ROSE CITY OFFICE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 548 | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | MI | ||||||||
PostalCode: | 492040548 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5177843950 | ||||||||
FaxNumber: | 5177832728 | ||||||||
Practice Location | |||||||||
Address1: | 300 W WASHINGTON AVE | ||||||||
Address2: | SUITE 060 | ||||||||
City: | JACKSON | ||||||||
State: | MI | ||||||||
PostalCode: | 492012180 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5177875970 | ||||||||
FaxNumber: | 5177873353 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/09/2006 | ||||||||
LastUpdateDate: | 09/02/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAYO | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNT SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 5177843950 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   | MI | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1041C0700X |   | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207R00000X |   | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 124Q00000X |   | MI | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Hygienist |   | 363AM0700X |   | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X |   | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207Q00000X |   | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 500C807070 | 01 | MI | BCBSM GROUP PROVIDER | OTHER | 700C810070 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |