Provider Demographics
NPI:1225070998
Name:MICHIGAN FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:MICHIGAN FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKESELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-536-8677
Mailing Address - Street 1:PO BOX 739
Mailing Address - Street 2:
Mailing Address - City:NAPOLEON
Mailing Address - State:MI
Mailing Address - Zip Code:49261-0739
Mailing Address - Country:US
Mailing Address - Phone:517-536-8677
Mailing Address - Fax:517-536-5225
Practice Address - Street 1:875 LAURENCE AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2966
Practice Address - Country:US
Practice Address - Phone:517-817-0280
Practice Address - Fax:517-787-0730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty