Basic Information
| Provider Information | |||||||||
| NPI: | 1578766952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAYKOVA | ||||||||
| FirstName: | VANIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487640779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893629411 | ||||||||
| FaxNumber: | 9893629925 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 S CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | HALE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487399272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897284211 | ||||||||
| FaxNumber: | 9897284334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C54998 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4301084171 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 700E012740 | 01 | MI | BCBSM GROUP NUMBER | OTHER | 1235131137 | 01 | MI | BCBSM - BLH | OTHER | 1578766952 | 05 | MI | MEDICAID |