Provider Demographics
NPI:1184734576
Name:MARILYN VIERA MSW DO PLC
Entity type:Organization
Organization Name:MARILYN VIERA MSW DO PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:VIERA
Authorized Official - Suffix:
Authorized Official - Credentials:MSW DO
Authorized Official - Phone:517-482-8735
Mailing Address - Street 1:1515 LAKE LANSING RD
Mailing Address - Street 2:SUITE C-1
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-3753
Mailing Address - Country:US
Mailing Address - Phone:517-482-8735
Mailing Address - Fax:
Practice Address - Street 1:1515 LAKE LANSING RD
Practice Address - Street 2:SUITE C-1
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3753
Practice Address - Country:US
Practice Address - Phone:517-482-8735
Practice Address - Fax:517-482-8744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011017207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0853302285OtherBCBS OF MICHIGAN
MI0M33820Medicare ID - Type Unspecified