Provider Demographics
NPI:1306866215
Name:CENTRAL MICHIGAN FAMILY PRACTICE
Entity Type:Organization
Organization Name:CENTRAL MICHIGAN FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:W
Authorized Official - Last Name:HORSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:989-588-6153
Mailing Address - Street 1:522 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FARWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48622
Mailing Address - Country:US
Mailing Address - Phone:989-588-6153
Mailing Address - Fax:989-588-6194
Practice Address - Street 1:522 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:FARWELL
Practice Address - State:MI
Practice Address - Zip Code:48622
Practice Address - Country:US
Practice Address - Phone:989-588-6153
Practice Address - Fax:989-588-6194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014871207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1012731OtherMCLAREN HEALTH PLAN
MI0101842OtherPHP UNITED HEALTHCARE
MI114637450Medicaid
MI0853701105OtherBLUE CROSS BLUE SHIELD
610677100OtherUS DEPT OF LABOR
N99520001Medicare ID - Type Unspecified
MI1012731OtherMCLAREN HEALTH PLAN