1174824643 NPI number — WOLVERINE STATE INPATIENT SERVICES, PLLC

Table of content: (NPI 1174824643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174824643 NPI number — WOLVERINE STATE INPATIENT SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOLVERINE STATE INPATIENT SERVICES, PLLC
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:
1174824643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
815 S PALAFOX ST
Provider Second Line Business Mailing Address:
300
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32502-5960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-444-7009
Provider Business Mailing Address Fax Number:
800-305-3233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
703 N MCEWAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48617-1440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-712-2472
Provider Business Practice Location Address Fax Number:
214-712-2444
Provider Enumeration Date:
11/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WEBSTER
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-712-2000

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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