Provider Demographics
NPI:1457496952
Name:VICENTE D CABANSAG JR MD PC
Entity Type:Organization
Organization Name:VICENTE D CABANSAG JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICENTE
Authorized Official - Middle Name:D
Authorized Official - Last Name:CABANSAG
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:269-651-9302
Mailing Address - Street 1:68930 VINEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-8899
Mailing Address - Country:US
Mailing Address - Phone:269-651-9302
Mailing Address - Fax:269-651-4809
Practice Address - Street 1:68930 VINEWOOD AVE
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-8899
Practice Address - Country:US
Practice Address - Phone:269-651-9302
Practice Address - Fax:269-651-4809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080148207Q00000X
MI033706208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI020750206OtherBCBS OF MICHIGAN
MI1074410 TYPE 10Medicaid
MI0131026OtherIBA
MI020750206OtherBCBS OF MICHIGAN
MI1074410 TYPE 10Medicaid