Basic Information
| Provider Information | |||||||||
| NPI: | 1912923970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACCHIARELLA | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KROHN | ||||||||
| OtherFirstName: | NANCY | ||||||||
| OtherMiddleName: | B | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1005 SOUTH VAN DYKE | ||||||||
| Address2: | |||||||||
| City: | BAD AXE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892693923 | ||||||||
| FaxNumber: | 9892693983 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 SOUTH VAN DYKE | ||||||||
| Address2: | |||||||||
| City: | BAD AXE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892693923 | ||||||||
| FaxNumber: | 9892693983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 02/01/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 5101013377 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1653210895 | 01 | MI | BCBSM | OTHER | 4624157 | 05 | MI | MEDICAID |