Provider Demographics
NPI:1487648374
Name:PINE TREES MEDICAL OFFICE PC
Entity Type:Organization
Organization Name:PINE TREES MEDICAL OFFICE PC
Other - Org Name:MARK A KALLUS MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-688-4842
Mailing Address - Street 1:11610 WALDRON RD
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:MI
Mailing Address - Zip Code:49249-9637
Mailing Address - Country:US
Mailing Address - Phone:517-688-4842
Mailing Address - Fax:517-688-4842
Practice Address - Street 1:11610 WALDRON RD
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:MI
Practice Address - Zip Code:49249-9637
Practice Address - Country:US
Practice Address - Phone:517-688-4842
Practice Address - Fax:517-688-4842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028315207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP41335OtherBLUE CARE NETWORK HMO
MI1 106914130OtherBCBS
MI4462854Medicaid
B43180Medicare UPIN
MI1 106914130OtherBCBS