Basic Information
Provider Information | |||||||||
NPI: | 1225177678 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MCLAREN GREATER LANSING | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 401 W GREENLAWN AVE | ||||||||
Address2: |   | ||||||||
City: | LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 489102819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5179756000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2104 JOLLY RD | ||||||||
Address2: | SUITE 220 | ||||||||
City: | OKEMOS | ||||||||
State: | MI | ||||||||
PostalCode: | 48864 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5173812700 | ||||||||
FaxNumber: | 5173812727 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2007 | ||||||||
LastUpdateDate: | 08/02/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THOMPSON | ||||||||
AuthorizedOfficialFirstName: | DALE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 5179757555 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 4208757700 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |