Basic Information
Provider Information | |||||||||
NPI: | 1326012634 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANCHEZ | ||||||||
FirstName: | GUILLERMO | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5900 BYRON CENTER AVE SW | ||||||||
Address2: | MEDICAL ADMINISTRATION | ||||||||
City: | WYOMING | ||||||||
State: | MI | ||||||||
PostalCode: | 495199606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6162523243 | ||||||||
FaxNumber: | 6162520260 | ||||||||
Practice Location | |||||||||
Address1: | 5900 BYRON CENTER AVE SW | ||||||||
Address2: |   | ||||||||
City: | WYOMING | ||||||||
State: | MI | ||||||||
PostalCode: | 495199606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6162527789 | ||||||||
FaxNumber: | 6162526939 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/14/2006 | ||||||||
LastUpdateDate: | 07/23/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0203X | 210509 | MA | N |   | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0204X | 210509 | MA | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 210509 | MA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 0167984 | 05 | MA |   | MEDICAID | D16078476 | 05 | MI |   | MEDICAID |