Provider Demographics
NPI:1437609781
Name:PORT HURON INTERNAL MEDICINE
Entity Type:Organization
Organization Name:PORT HURON INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERNAL MEDICINE PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:JARAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-987-1000
Mailing Address - Street 1:2540 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6405
Mailing Address - Country:US
Mailing Address - Phone:586-634-0055
Mailing Address - Fax:
Practice Address - Street 1:2540 16TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6405
Practice Address - Country:US
Practice Address - Phone:586-634-0055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704272224364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Multi-Specialty