Provider Demographics
NPI:1467420901
Name:INTERNAL MEDICINE OF NORTHERN MICHIGAN PLLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE OF NORTHERN MICHIGAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-487-2460
Mailing Address - Street 1:560 W MITCHELL ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2275
Mailing Address - Country:US
Mailing Address - Phone:231-487-2460
Mailing Address - Fax:231-487-6596
Practice Address - Street 1:560 W MITCHELL ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2275
Practice Address - Country:US
Practice Address - Phone:231-487-2460
Practice Address - Fax:231-487-6596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
99111316OtherHIRSP
CF8034OtherRR MEDICARE
619706OtherANTHEM BCBS
110B410170OtherMICHIGAN BCBS
20146OtherPRIORITY HEALTH GROUP ID
99111316OtherHIRSP