Provider Demographics
NPI:1508229980
Name:CHARLEVOIX PHYSICIANS CLINIC
Entity Type:Organization
Organization Name:CHARLEVOIX PHYSICIANS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:TALMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-547-6519
Mailing Address - Street 1:14709 W UPRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1949
Mailing Address - Country:US
Mailing Address - Phone:231-547-6519
Mailing Address - Fax:231-547-5404
Practice Address - Street 1:14709 W. UPRIGHT
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720
Practice Address - Country:US
Practice Address - Phone:231-547-6519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301049260174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE31691Medicare UPIN