Provider Demographics
NPI:1275718900
Name:WEST SHORE WOMENS PRACTICE PC
Entity Type:Organization
Organization Name:WEST SHORE WOMENS PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-398-0222
Mailing Address - Street 1:1293 E PARKDALE AVE
Mailing Address - Street 2:SUITE 1200A
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-8904
Mailing Address - Country:US
Mailing Address - Phone:231-398-0222
Mailing Address - Fax:231-398-0225
Practice Address - Street 1:1293 E PARKDALE AVE
Practice Address - Street 2:SUITE 1200A
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-8904
Practice Address - Country:US
Practice Address - Phone:231-398-0222
Practice Address - Fax:231-398-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079496207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMF079496OtherSTATE LICENSE NUMBER
MI1605115302OtherBLUE CARE NETWORK PIN
MI1605115302OtherBCBS PIN
MI1605115302OtherBLUE CARE NETWORK PIN
MII58910Medicare UPIN