1558360131 NPI number — DR. MICHAEL L NOWAK D.O.

Table of content: DR. MICHAEL L NOWAK D.O. (NPI 1558360131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558360131 NPI number — DR. MICHAEL L NOWAK D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOWAK
Provider First Name:
MICHAEL
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1558360131
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 W COUNTRY CLUB RD
Provider Second Line Business Mailing Address:
STE# 203
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88201-5205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-624-4646
Provider Business Mailing Address Fax Number:
575-625-8498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 W COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
STE# 203
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88201-5205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-624-4646
Provider Business Practice Location Address Fax Number:
575-625-8498
Provider Enumeration Date:
07/18/2005

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: 207V00000X , with the licence number:  2619 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: A-1602-11 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NPI & TIN# . This is a "BCBS OF NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 000000007795 . This is a "ANTHEM BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0457349 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 310884319026 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2380630 . This is a "CIGNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 160029113 . This is a "RAILROAD MEDICARE PALMETT" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 40004279 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4341671 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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