Provider Demographics
NPI:1407800931
Name:CRISTO REY COMMUNITY CENTER
Entity Type:Organization
Organization Name:CRISTO REY COMMUNITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:H
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-371-1700
Mailing Address - Street 1:1717 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-4529
Mailing Address - Country:US
Mailing Address - Phone:517-371-1700
Mailing Address - Fax:517-371-4245
Practice Address - Street 1:1717 N HIGH ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-4529
Practice Address - Country:US
Practice Address - Phone:517-371-1700
Practice Address - Fax:517-371-4245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISL037010207V00000X
MIPC049423208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI010C362090OtherBCBS COOKE
MI3148943Medicaid
MI0C36209014Medicare ID - Type UnspecifiedMEDICARE LEE
MIE16082Medicare UPIN
MIB45983Medicare UPIN
MI0C36209Medicare ID - Type UnspecifiedMEDICARE GROUP