Basic Information
| Provider Information | |||||||||
| NPI: | 1912066093 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADDISON COMMUNITY PHYSICIAN SERVICES ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 S PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481987914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345474900 | ||||||||
| FaxNumber: | 7345471161 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 S PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481987914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345474900 | ||||||||
| FaxNumber: | 7345471161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCRIPKO | ||||||||
| AuthorizedOfficialFirstName: | JOANN | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7345471174 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 700H111110 | 01 | MI | BCBS OF MI | OTHER |