Basic Information
| Provider Information | |||||||||
| NPI: | 1255367009 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HURLEY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HURLEY PODIATRY GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HURLEY PLZ | ||||||||
| Address2: | 5TH FLOOR S.O.N. | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485035902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107627038 | ||||||||
| FaxNumber: | 8107600440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HURLEY PLZ | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485035902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102579000 | ||||||||
| FaxNumber: | 8107600440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHANG | ||||||||
| AuthorizedOfficialFirstName: | RUTH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8102579952 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HURLEY MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 250040 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 0B57623 | 01 | MI | BLUE SHIELD | OTHER |