WATERFORD PEDIATRICS
Complete NPI Record 1104082148
General Practice in Waterford, MI
Active since July 30, 2008
Complete NPI Dataset
This page contains the complete raw NPPES record for Waterford Pediatrics (NPI 1104082148), a general practice organization in Waterford, MI. All 50 fields on file are listed with their current values and official NPPES definitions, exactly as recorded in the National Plan and Provider Enumeration System. Only fields that contain data are included, so the number of fields shown varies from one NPI record to another.
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Registry File Document Utilities
- NPI: 1104082148 Field 1/50
- The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
- Entity Type Code: 2 Field 2/50
- Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
- Employer Identification Number EIN: Not available Field 3/50
- The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
- Provider Organization Name Legal Business Name: WATERFORD PEDIATRICS Field 4/50
- The name of the organization provider. If the provider is an organization, this is the legal business name.
- Provider First Line Business Mailing Address: 4185 HIGHLAND RD Field 5/50
- The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
- Provider Business Mailing Address City Name: WATERFORD Field 6/50
- The city name in the mailing address of the provider being identified.
- Provider Business Mailing Address State Name: MI Field 7/50
- The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
- Provider Business Mailing Address Postal Code: 48328 Field 8/50
- The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
- Provider Business Mailing Address Country Code If outside U S : US Field 9/50
- The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
- Provider Business Mailing Address Telephone Number: 2486488930 Field 10/50
- The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
- Provider Business Mailing Address Fax Number: 2486488931 Field 11/50
- The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
- Provider First Line Business Practice Location Address: 4185 HIGHLAND RD Field 12/50
- The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
- Provider Business Practice Location Address City Name: WATERFORD Field 13/50
- The city name in the location address of the provider being identified.
- Provider Business Practice Location Address State Name: MI Field 14/50
- The State code in the location of the provider being identified.
- Provider Business Practice Location Address Postal Code: 48328 Field 15/50
- The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
- Provider Business Practice Location Address Country Code If outside U S : US Field 16/50
- The country code in the location address of the provider being identified.
- Provider Business Practice Location Address Telephone Number: 2486488930 Field 17/50
- The telephone number associated with the location address of the provider being identified.
- Provider Business Practice Location Address Fax Number: 2486488931 Field 18/50
- The fax number associated with the location address of the provider being identified.
- Authorized Official Last Name: INMAN Field 21/50
- The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
- Authorized Official First Name: VICKI Field 22/50
- The first name of the authorized official.
- Authorized Official Middle Name: L Field 23/50
- The middle name of the authorized official.
- Authorized Official Title or Position: BILLING MGR Field 24/50
- The title or position of the authorized official.
- Authorized Official Telephone Number: 2486664266 Field 25/50
- The 10-position telephone number of the authorized official.
- Healthcare Provider Taxonomy Code 1: 208D00000X Field 26/50
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Provider License Number 1: MK057394 Field 27/50
- The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with "provider taxonomy code".
- Provider License Number State Code 1: MI Field 28/50
- The two-letter state code representing the U.S. state or territory that issued the provider's license. This field is linked to the Provider License Number field and identifies the jurisdiction where that license is valid. A provider may have multiple state codes if they hold licenses in more than one state.
- Healthcare Provider Primary Taxonomy Switch 1: Y Field 29/50
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Other Provider Identifier 1: 021121 Field 30/50
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 1: 01 Field 31/50
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier Issuer 1: MIDWEST Field 32/50
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 2: C7543 Field 33/50
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 2: 01 Field 34/50
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier Issuer 2: MCARE Field 35/50
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 3: 15486 Field 36/50
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 3: 01 Field 37/50
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier Issuer 3: HEALTH PLAN Field 38/50
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 4: 4149524 Field 39/50
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 4: 05 Field 40/50
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 4: MI Field 41/50
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier 5: 0634011 Field 42/50
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 5: 01 Field 43/50
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier Issuer 5: BCBS Field 44/50
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 6: 120911 Field 45/50
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 6: 01 Field 46/50
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier Issuer 6: CARECHOICES Field 47/50
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Is Organization Subpart: N Field 48/50
- Indicates whether the provider is a subpart of a larger organization. This is a single-character code: "Y" means the entity is an organizational subpart, while "N" means it is not. Subparts typically include hospital departments, clinics, or other distinct units that fall under a parent organization.
- Authorized Official Name Prefix Text: MRS. Field 49/50
- The prefix used in the name of the authorized official associated with the provider's NPI record. Examples include Mr., Ms., Mrs., Dr., or other common professional or personal prefixes.
- Healthcare Provider Taxonomy Group 1: 193400000X SINGLE SPECIALTY GROUP Field 50/50
- Specifies whether the provider is part of a single-specialty or multi-specialty business group. The possible values are: 193200000X – Multi-Specialty Group or 193400000X – Single Specialty Group. This field helps distinguish the organizational structure of a provider group.
Other Provider Identifiers 8
Legacy and payer-issued identifiers reported to the NPPES registry for this provider.
0634011 Other
Identifier 1/8Issuer: Bcbs
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
G97370 Medicare UPIN
Identifier 2/8State: MI
Medicare UPIN (Unique Physician Identification Number): A legacy six-character alphanumeric identifier previously issued by Medicare to individual physicians before being retired and replaced by the NPI system.
Medicare UPIN (Unique Physician Identification Number): A legacy six-character alphanumeric identifier previously issued by Medicare to individual physicians before being retired and replaced by the NPI system.
120911 Other
Identifier 3/8Issuer: Carechoices
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
15486 Other
Identifier 4/8Issuer: Health Plan
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
OP13980 Medicare PIN
Identifier 5/8State: MI
Medicare PIN: Used in legacy data fields alongside a healthcare provider's National Provider Identifier (NPI) to designate legacy Medicare provider numbers.
Medicare PIN: Used in legacy data fields alongside a healthcare provider's National Provider Identifier (NPI) to designate legacy Medicare provider numbers.
C7543 Other
Identifier 6/8Issuer: Mcare
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
021121 Other
Identifier 7/8Issuer: Midwest
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
4149524 Medicaid
Identifier 8/8State: MI
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
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