Provider Demographics
NPI:1093994337
Name:NORTHERN MICHIGAN VASCULAR CENTER P.C.
Entity Type:Organization
Organization Name:NORTHERN MICHIGAN VASCULAR CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:COLBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-935-0390
Mailing Address - Street 1:3930 CEDAR RUN RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9687
Mailing Address - Country:US
Mailing Address - Phone:231-935-0390
Mailing Address - Fax:231-935-0395
Practice Address - Street 1:3930 CEDAR RUN RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-9687
Practice Address - Country:US
Practice Address - Phone:231-935-0390
Practice Address - Fax:231-935-0395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010792152086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P52830Medicare PIN