1104868371 NPI number — RAY H KING M.D.

Table of content: RAY H KING M.D. (NPI 1104868371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104868371 NPI number — RAY H KING M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KING
Provider First Name:
RAY
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1104868371
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 67000
Provider Second Line Business Mailing Address:
DEPARTMENT 272801
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48267-0002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-841-6913
Provider Business Mailing Address Fax Number:
517-841-6917

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 HINCKLEY BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49203-6125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-784-0588
Provider Business Practice Location Address Fax Number:
517-784-3866
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4301045040 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00402205 . This is a "RR MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080083111 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 105190507 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5340399 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5464083 . This is a "AETNA USHEALTHCARE" identifier . This identifiers is of the category "OTHER".




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