Basic Information
Provider Information | |||||||||
NPI: | 1881825073 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AIRWAY OXYGEN INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9950 | ||||||||
Address2: |   | ||||||||
City: | WYOMING | ||||||||
State: | MI | ||||||||
PostalCode: | 495099918 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6162473900 | ||||||||
FaxNumber: | 6162470776 | ||||||||
Practice Location | |||||||||
Address1: | 2540 28TH ST SW | ||||||||
Address2: |   | ||||||||
City: | WYOMING | ||||||||
State: | MI | ||||||||
PostalCode: | 495192106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6163288780 | ||||||||
FaxNumber: | 6163288782 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2009 | ||||||||
LastUpdateDate: | 08/11/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NYHUIS | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6162473900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GRANITE HOLDINGS INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 332BX2000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
ID | Type | State | Issuer | Description | 540D10642 | 01 | MI | BLUE CROSS/BLUE SHIELD OF MICHIGAN | OTHER | 5019426 | 05 | MI |   | MEDICAID |