Provider Demographics
NPI:1346593746
Name:DOCTOR MICHAEL TRAVERS FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:DOCTOR MICHAEL TRAVERS FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:TRAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-293-6809
Mailing Address - Street 1:PO BOX 2949
Mailing Address - Street 2:414 E WOODIN
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816-2949
Mailing Address - Country:US
Mailing Address - Phone:509-293-6809
Mailing Address - Fax:509-888-2231
Practice Address - Street 1:414 E WOODIN AVE
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816-9648
Practice Address - Country:US
Practice Address - Phone:509-293-6809
Practice Address - Fax:509-888-2231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-23
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028342207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA63646Medicare UPIN