1407838683 NPI number — MICHAEL F RECKKER CRNA

Table of content: MICHAEL F RECKKER CRNA (NPI 1407838683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407838683 NPI number — MICHAEL F RECKKER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RECKKER
Provider First Name:
MICHAEL
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1407838683
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 FOREST HILLS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARQUETTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49855-9619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-226-2608
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
580 W COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-2705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-225-3406
Provider Business Practice Location Address Fax Number:
906-225-3094
Provider Enumeration Date:
11/15/2005

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: 367500000X , with the licence number:  4704183791 , 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: 430023881 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 103073646 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: MR183791 . This is a "BLUESHIELD PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 43401100 . This is a "WISC MEDICAID PIN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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