Provider Demographics
NPI:1114222031
Name:LIGHTHOUSE FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:LIGHTHOUSE FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:G.
Authorized Official - Middle Name:BLAIR
Authorized Official - Last Name:DOWDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-824-4222
Mailing Address - Street 1:4071 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3801
Mailing Address - Country:US
Mailing Address - Phone:810-824-4222
Mailing Address - Fax:810-824-4220
Practice Address - Street 1:4071 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3801
Practice Address - Country:US
Practice Address - Phone:810-824-4222
Practice Address - Fax:810-824-4220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088847207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1750379194Medicaid
MI1750379194Medicaid