Provider Demographics
NPI:1477702744
Name:SHEILA GENDICH M D PLC
Entity Type:Organization
Organization Name:SHEILA GENDICH M D PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TYSICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-627-8881
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-0099
Mailing Address - Country:US
Mailing Address - Phone:989-227-9902
Mailing Address - Fax:989-227-9911
Practice Address - Street 1:1207 N US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-1139
Practice Address - Country:US
Practice Address - Phone:989-227-9902
Practice Address - Fax:989-227-9911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G55405Medicare UPIN