Basic Information
Provider Information | |||||||||
NPI: | 1740498799 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MCLAREN LAPEER REGION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1375 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LAPEER | ||||||||
State: | MI | ||||||||
PostalCode: | 484461350 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8106675500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1375 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LAPEER | ||||||||
State: | MI | ||||||||
PostalCode: | 484461350 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8106675500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/21/2007 | ||||||||
LastUpdateDate: | 06/26/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KORTE | ||||||||
AuthorizedOfficialFirstName: | FRED | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
AuthorizedOfficialTelephone: | 8103422000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 23D0373149 | MI | Y |   | Laboratories | Clinical Medical Laboratory |   |
ID Information
ID | Type | State | Issuer | Description | 690D415040 | 01 | MI | BLUE SHIELD PIN NUMBER | OTHER |