Provider Demographics
NPI:1164695839
Name:COUNTRYSIDE HEALTH, PLLC
Entity Type:Organization
Organization Name:COUNTRYSIDE HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:E
Authorized Official - Last Name:DUNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:231-743-6002
Mailing Address - Street 1:PO BOX 1024
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-6024
Mailing Address - Country:US
Mailing Address - Phone:231-775-6076
Mailing Address - Fax:231-775-0027
Practice Address - Street 1:107 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:MI
Practice Address - Zip Code:49665-9642
Practice Address - Country:US
Practice Address - Phone:231-743-6002
Practice Address - Fax:231-743-6081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty