Provider Demographics
NPI:1033290796
Name:FOWLERVILLE MEDICAL CENTER, PLC
Entity Type:Organization
Organization Name:FOWLERVILLE MEDICAL CENTER, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NORINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-223-7900
Mailing Address - Street 1:202 E VAN RIPER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836-7947
Mailing Address - Country:US
Mailing Address - Phone:517-223-7900
Mailing Address - Fax:517-223-7635
Practice Address - Street 1:202 E VAN RIPER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FOWLERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48836-7947
Practice Address - Country:US
Practice Address - Phone:517-223-7900
Practice Address - Fax:517-223-7635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060017207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0477259Medicaid
MI0477259Medicaid
MI0P09430Medicare PIN