1497715130 NPI number — SUSAN GAYLE WIERS NP

Table of content: SUSAN GAYLE WIERS NP (NPI 1497715130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497715130 NPI number — SUSAN GAYLE WIERS NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIERS
Provider First Name:
SUSAN
Provider Middle Name:
GAYLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1497715130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43750 GARFIELD RD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
CLINTON TWP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48038-1135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-226-6865
Provider Business Mailing Address Fax Number:
586-226-6880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35050 23 MILE RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
NEW BALTIMORE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48047-3606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-725-0477
Provider Business Practice Location Address Fax Number:
586-725-8835
Provider Enumeration Date:
03/25/2006

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: 163WG0000X , with the licence number:  4704135893 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 4704135893 , 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: 50-0-86-6532-0 . This is a "BCBS PIN NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4378385 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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