Provider Demographics
NPI:1326227786
Name:PREECHA SUPANWANID MD PC
Entity Type:Organization
Organization Name:PREECHA SUPANWANID MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PREECHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPANWANID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-336-6950
Mailing Address - Street 1:921 ABBOT RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-3170
Mailing Address - Country:US
Mailing Address - Phone:517-336-6950
Mailing Address - Fax:517-336-6952
Practice Address - Street 1:921 ABBOT RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-3170
Practice Address - Country:US
Practice Address - Phone:517-336-6950
Practice Address - Fax:517-336-6952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037471174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0338503OtherBLUE CROSS BLUE SHIELD
MI1391276Medicaid
MI1391276Medicaid