Provider Demographics
NPI:1386659043
Name:NORTHWEST MICHIGAN SURGICAL GROUP, P.C.
Entity Type:Organization
Organization Name:NORTHWEST MICHIGAN SURGICAL GROUP, P.C.
Other - Org Name:PROFESSIONAL CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCDONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-935-2844
Mailing Address - Street 1:1221 SIXTH STREET
Mailing Address - Street 2:STE. 208
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684
Mailing Address - Country:US
Mailing Address - Phone:231-935-2844
Mailing Address - Fax:231-935-2850
Practice Address - Street 1:1221 SIXTH STREET
Practice Address - Street 2:STE. 208
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-935-2844
Practice Address - Fax:231-935-2850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208600000X, 2086S0129X
MIJM008369208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON50330Medicare PIN
E37508Medicare UPIN