1356393482 NPI number — STEPHEN N DALLAS M.D., M.A.

Table of content: STEPHEN N DALLAS M.D., M.A. (NPI 1356393482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356393482 NPI number — STEPHEN N DALLAS M.D., M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DALLAS
Provider First Name:
STEPHEN
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D., M.A.
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:
1356393482
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3601 S 9TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49009-9538
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-383-6789
Provider Business Mailing Address Fax Number:
269-383-6767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3601 S 9TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49009-9538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-383-6789
Provider Business Practice Location Address Fax Number:
269-383-6767
Provider Enumeration Date:
05/17/2006

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: 207R00000X , with the licence number:  4301067063 , 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: 4236764 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com