Provider Demographics
NPI:1275509036
Name:TAWAS BAY FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:TAWAS BAY FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MA
Authorized Official - Prefix:MS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HEILIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-362-5688
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48764-0369
Mailing Address - Country:US
Mailing Address - Phone:989-362-3447
Mailing Address - Fax:
Practice Address - Street 1:541 W LAKE ST
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-5105
Practice Address - Country:US
Practice Address - Phone:989-362-3447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080012620 L0601OtherBLUE CARE NETWORK
MI0803518971OtherBCBSM
MI16056OtherBLUE CROSS BLUE SHIELD FACILITY
MI2897941Medicaid
MI2897941OtherMOLINA HEALTHCARE
MICC00000010OtherHEALTH PLUS
MI080012620 L0601OtherBLUE CARE NETWORK
MI080012620 L0601OtherBLUE CARE NETWORK
MI2897941Medicaid
MI=========102OtherCOMMUNITY CHOICE MICHIGAN