Provider Demographics
NPI:1184642886
Name:ARCHIBALD W. DETTMAN
Entity Type:Organization
Organization Name:ARCHIBALD W. DETTMAN
Other - Org Name:SHIAWASSEE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARCHIBALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:DETTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:989-743-3415
Mailing Address - Street 1:115 N SHIAWASSEE ST
Mailing Address - Street 2:
Mailing Address - City:CORUNNA
Mailing Address - State:MI
Mailing Address - Zip Code:48817-1435
Mailing Address - Country:US
Mailing Address - Phone:989-743-3415
Mailing Address - Fax:989-743-6180
Practice Address - Street 1:115 N SHIAWASSEE ST
Practice Address - Street 2:
Practice Address - City:CORUNNA
Practice Address - State:MI
Practice Address - Zip Code:48817-1435
Practice Address - Country:US
Practice Address - Phone:989-743-3415
Practice Address - Fax:989-743-6180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006898208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICH2727OtherTRAVELERS MC GROUP NUMBER
MICH2727OtherTRAVELERS MC GROUP NUMBER