Provider Demographics
NPI:1376643155
Name:PETER S. VANDEMARK, MD, PC
Entity Type:Organization
Organization Name:PETER S. VANDEMARK, MD, PC
Other - Org Name:BIG RAPIDS INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:S
Authorized Official - Last Name:VANDEMARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-796-4406
Mailing Address - Street 1:705 OAK STREET
Mailing Address - Street 2:SUITE 11
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307
Mailing Address - Country:US
Mailing Address - Phone:231-796-4406
Mailing Address - Fax:231-796-2770
Practice Address - Street 1:705 OAK STREET
Practice Address - Street 2:SUITE 11
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307
Practice Address - Country:US
Practice Address - Phone:231-796-4406
Practice Address - Fax:231-796-2770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038966207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3377875Medicaid
MI0540004OtherBLUE CROSS BLUE SHIELD
MI0540004OtherBLUE CROSS BLUE SHIELD
MI3377875Medicaid