Basic Information
| Provider Information | |||||||||
| NPI: | 1033107867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PASSAL | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 LAPEER AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486071208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897596464 | ||||||||
| FaxNumber: | 9893998233 | ||||||||
| Practice Location | |||||||||
| Address1: | 1522 JANES AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486011819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897550316 | ||||||||
| FaxNumber: | 9897550956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301038058 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | P74211 | 01 | BLUE CARE NETWORK OF MICH | OTHER | 1033107867 | 05 | MI | MEDICAID | 0983722 | 01 | HEALTHPLUS OF MICHIGAN | OTHER | 1010623 | 01 | MCLAREN HEALTH PLAN | OTHER | 160G36111 | 01 | BCBS OF MI | OTHER | 2987397 | 01 | MOLINA HEALTH CARE OF MIC | OTHER | 381908328 | 01 | TRICARE | OTHER | 104 | 01 | COMMUNITY CHOICE OF MICHI | OTHER | 121653 | 01 | GREAT LAKES HEALTH PLAN | OTHER |