Healthcare Provider Details

I. General information

NPI: 1225606551
Provider Name (Legal Business Name): PAYTON RILEY PTACEK BS, MPA, MCJ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1484 N M 52
OWOSSO MI
48867-1235
US

IV. Provider business mailing address

2100 HEMMETER RD
SAGINAW MI
48603-3944
US

V. Phone/Fax

Practice location:
  • Phone: 770-373-5822
  • Fax: 248-712-4381
Mailing address:
  • Phone: 989-799-2100
  • Fax: 989-799-2637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: