Basic Information
Provider Information | |||||||||
NPI: | 1801013271 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GENESYS REGIONAL MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2015 | ||||||||
Address2: |   | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485012015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8106065830 | ||||||||
FaxNumber: | 8106065639 | ||||||||
Practice Location | |||||||||
Address1: | 4642 GENESYS PKWY | ||||||||
Address2: |   | ||||||||
City: | GRAND BLANC | ||||||||
State: | MI | ||||||||
PostalCode: | 484398067 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8106065830 | ||||||||
FaxNumber: | 8106065639 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2007 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LABAERE DO | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL EDUCATION DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8107154300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X |   | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 7G00009 | 01 | MI | HEALTHPLUS GROUP # | OTHER |