Provider Demographics
NPI:1225014715
Name:SHEPHERD OF HOPE CLINIC PC
Entity Type:Organization
Organization Name:SHEPHERD OF HOPE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WIGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-946-7360
Mailing Address - Street 1:1028 HANNAH AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2963
Mailing Address - Country:US
Mailing Address - Phone:231-946-7360
Mailing Address - Fax:231-929-4775
Practice Address - Street 1:1028 HANNAH AVE
Practice Address - Street 2:SUITE D
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2963
Practice Address - Country:US
Practice Address - Phone:231-946-7360
Practice Address - Fax:231-929-4775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2100506Medicaid
MIN1308000Medicare ID - Type Unspecified
MI2100506Medicaid