Provider Demographics
NPI:1225205438
Name:ARTESIAN SPRINGS MEDICAL CLINIC
Entity Type:Organization
Organization Name:ARTESIAN SPRINGS MEDICAL CLINIC
Other - Org Name:TRICIA ANN MCGILLIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MCGILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C, MPAS
Authorized Official - Phone:231-743-0150
Mailing Address - Street 1:100 E MAIN ST
Mailing Address - Street 2:PO BOX 578
Mailing Address - City:MARION
Mailing Address - State:MI
Mailing Address - Zip Code:49665-9642
Mailing Address - Country:US
Mailing Address - Phone:231-743-0150
Mailing Address - Fax:231-743-0152
Practice Address - Street 1:100 E MAIN ST
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:231-743-0150
Practice Address - Fax:231-743-0152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003629363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P47510Medicare PIN