Basic Information
| Provider Information | |||||||||
| NPI: | 1912280074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SZATKOWSKI | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HYMES | ||||||||
| OtherFirstName: | ANITA | ||||||||
| OtherMiddleName: | JOY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 38935 ANN ARBOR RD | ||||||||
| Address2: | CREDENTIALING/PAYER CONTRACTING | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481503397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346320175 | ||||||||
| FaxNumber: | 7346320182 | ||||||||
| Practice Location | |||||||||
| Address1: | 13700 ST FRANCIS BLVD | ||||||||
| Address2: | EMERGENCY MEDICINE DEPARTMENT | ||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231143222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045947950 | ||||||||
| FaxNumber: | 8045947955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2011 | ||||||||
| LastUpdateDate: | 09/26/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110840425 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | CAQH | OTHER |