Provider Demographics
NPI:1093995078
Name:WILLIAM T MANGAN JR, DO PLLC
Entity Type:Organization
Organization Name:WILLIAM T MANGAN JR, DO PLLC
Other - Org Name:FAMILY HEALT H CENTER OF WILLIAMSTON, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MANGAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:517-655-3979
Mailing Address - Street 1:319 W GRAND RIVER AVE
Mailing Address - Street 2:P O BOX 410
Mailing Address - City:WILLIAMSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48895-1300
Mailing Address - Country:US
Mailing Address - Phone:517-655-3979
Mailing Address - Fax:
Practice Address - Street 1:319 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895-1300
Practice Address - Country:US
Practice Address - Phone:517-655-3979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011930207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP19340Medicare PIN