Provider Demographics
NPI:1871699371
Name:MARIO CHAVES PC
Entity type:Organization
Organization Name:MARIO CHAVES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CESAR
Authorized Official - Middle Name:MARIO
Authorized Official - Last Name:CHAVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-729-4300
Mailing Address - Street 1:818 W KING ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2116
Mailing Address - Country:US
Mailing Address - Phone:989-729-4300
Mailing Address - Fax:989-729-4303
Practice Address - Street 1:818 W KING ST
Practice Address - Street 2:SUITE 103
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2116
Practice Address - Country:US
Practice Address - Phone:989-729-4300
Practice Address - Fax:989-729-4303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086974207V00000X
MI4704234443363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1607810341OtherBLUE CROSS BLUE SHIELD
MI104813851Medicaid
MI=========OtherTAX IDENTIFICATION NUMBER
MI1607810341OtherBLUE CROSS BLUE SHIELD