Provider Demographics
NPI:1467631804
Name:SEMINOLE SHORES INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:SEMINOLE SHORES INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:OGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-739-2192
Mailing Address - Street 1:433 SEMINOLE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-3743
Mailing Address - Country:US
Mailing Address - Phone:231-739-2192
Mailing Address - Fax:231-739-2343
Practice Address - Street 1:433 SEMINOLE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-3743
Practice Address - Country:US
Practice Address - Phone:231-739-2192
Practice Address - Fax:231-739-2343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062711207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1106110251OtherBLUE CROSS BLUE SHIELD
MI4559980Medicaid
MION85890Medicare PIN