Provider Demographics
NPI:1497780654
Name:TRI-CITY MEDICAL CLINIC PLC
Entity Type:Organization
Organization Name:TRI-CITY MEDICAL CLINIC PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AURORA
Authorized Official - Middle Name:B
Authorized Official - Last Name:MADANGUIT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-468-7684
Mailing Address - Street 1:6633 RED ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:COLOMA
Mailing Address - State:MI
Mailing Address - Zip Code:49038-8717
Mailing Address - Country:US
Mailing Address - Phone:269-468-7684
Mailing Address - Fax:269-468-7687
Practice Address - Street 1:6633 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:MI
Practice Address - Zip Code:49038-8717
Practice Address - Country:US
Practice Address - Phone:269-468-7684
Practice Address - Fax:269-468-7687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068832207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4341536Medicaid
MI4341536Medicaid
MIG51858Medicare UPIN