Provider Demographics
NPI:1497868111
Name:SUTTONS BAY MEDICAL CLINIC, PLC
Entity Type:Organization
Organization Name:SUTTONS BAY MEDICAL CLINIC, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:LAMMY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-271-5990
Mailing Address - Street 1:93B FOURTH ST
Mailing Address - Street 2:PO BOX 397
Mailing Address - City:SUTTONS BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49682-0397
Mailing Address - Country:US
Mailing Address - Phone:231-271-5990
Mailing Address - Fax:231-271-5959
Practice Address - Street 1:93B FOURTH ST
Practice Address - Street 2:
Practice Address - City:SUTTONS BAY
Practice Address - State:MI
Practice Address - Zip Code:49682-0397
Practice Address - Country:US
Practice Address - Phone:231-271-5990
Practice Address - Fax:231-271-5959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700D510020OtherBLUE CARE NETWORK
MI700D510020OtherBCBSM
MI0N19510OtherMEDICARE PART B
MI1982653242Medicaid
MI1588612972Medicaid
MI700D510020OtherBLUE CARE NETWORK
MI0N1951001Medicare PIN
MI1982653242Medicaid