Basic Information
Provider Information | |||||||||
NPI: | 1477535193 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AZABACHE | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5671 N SKEEL AVE | ||||||||
Address2: |   | ||||||||
City: | OSCODA | ||||||||
State: | MI | ||||||||
PostalCode: | 487501535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897392550 | ||||||||
FaxNumber: | 9893583750 | ||||||||
Practice Location | |||||||||
Address1: | 5671 N SKEEL AVE | ||||||||
Address2: |   | ||||||||
City: | OSCODA | ||||||||
State: | MI | ||||||||
PostalCode: | 487501535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897392550 | ||||||||
FaxNumber: | 9893583750 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2005 | ||||||||
LastUpdateDate: | 02/26/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 4301084673 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 4914101 | 05 | MI |   | MEDICAID | DA084673 | 01 | MI | BC-BS | OTHER |