Provider Demographics
NPI:1497719108
Name:MARQUETTE GENERAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:MARQUETTE GENERAL HOSPITAL, INC.
Other - Org Name:FAMILY CARE DOCTORS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:A. GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-225-4821
Mailing Address - Street 1:4602 DEPT
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122-0021
Mailing Address - Country:US
Mailing Address - Phone:906-225-3864
Mailing Address - Fax:906-225-3851
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 36
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3864
Practice Address - Fax:906-225-3851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207QS0010X
MI030113208000000X
MI0508762080P0205X
MI079600208100000X
MI5601004570363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E26000OtherBCBSM GROUP
MICI0319OtherRAILROAD MEDICARE
MI0N8996004OtherPA MEDICARE NUMBER
MIC31351OtherRAILROAD MEDICARE
MICN8789OtherRAILROAD MEDICARE
MICA1145OtherRAILROAD MEDICARE
MICA7435OtherRAILROAD MEDICARE
MI0E26000P02OtherPA IN MEDICARE GROUP
MIC31351OtherRAILROAD MEDICARE
MICA7435OtherRAILROAD MEDICARE