Provider Demographics
NPI:1518033976
Name:FAMILY TREE MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:FAMILY TREE MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:TROY
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-945-7497
Mailing Address - Street 1:1375 W GREEN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1718
Mailing Address - Country:US
Mailing Address - Phone:269-945-7497
Mailing Address - Fax:269-945-0214
Practice Address - Street 1:1375 W GREEN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1718
Practice Address - Country:US
Practice Address - Phone:269-945-7497
Practice Address - Fax:269-945-0214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM94420Medicare ID - Type Unspecified