Basic Information
| Provider Information | |||||||||
| NPI: | 1518005032 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCLAREN GREATER LANSING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 W GREENLAWN AVE | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489102819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179756000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2316 S CEDAR ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177024300 | ||||||||
| FaxNumber: | 5177024301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 08/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5179757555 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 500C313830 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |