Provider Demographics
NPI:1043501935
Name:PHYSICIAN SUPPORT SERVICE, INC.
Entity Type:Organization
Organization Name:PHYSICIAN SUPPORT SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-627-2181
Mailing Address - Street 1:11615 HARTEL RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-9165
Mailing Address - Country:US
Mailing Address - Phone:517-627-2181
Mailing Address - Fax:517-622-1242
Practice Address - Street 1:11615 HARTEL RD
Practice Address - Street 2:SUITE 206
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-9165
Practice Address - Country:US
Practice Address - Phone:517-627-2181
Practice Address - Fax:517-622-1242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030055261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0802363691OtherBCBSM PIN
MI0802363691OtherBCBSM PIN