1104097625 NPI number — MEADOWBROOK URGENT CARE PC

Table of content: (NPI 1104097625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104097625 NPI number — MEADOWBROOK URGENT CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEADOWBROOK URGENT CARE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104097625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25500 MEADOWBROOK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOVI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48375-1845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-476-8500
Provider Business Mailing Address Fax Number:
248-543-3434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37463 DUTTON RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PRAIRIEVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70769-3502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-313-3754
Provider Business Practice Location Address Fax Number:
225-313-6012
Provider Enumeration Date:
03/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WADLE
Authorized Official First Name:
RONA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MEDICAL DIRECTOR
Authorized Official Telephone Number:
248-476-8500

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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