Provider Demographics
NPI:1538102694
Name:PINE RIVER MEDICAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:PINE RIVER MEDICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HUMAN RESOURCE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:NEWCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-547-6554
Mailing Address - Street 1:14734 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720
Mailing Address - Country:US
Mailing Address - Phone:231-547-6554
Mailing Address - Fax:
Practice Address - Street 1:14734 PARK AVE
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720
Practice Address - Country:US
Practice Address - Phone:231-547-6554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDJ033990174400000X
MIFS039750174400000X
MIEN 045102174400000X
MIRT 046881174400000X
MIDM 076754174400000X
MIMB 070397174400000X
MIJM 066688174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG82379Medicare UPIN
MIA76725Medicare UPIN
MIB44367Medicare UPIN
MIB45305Medicare UPIN
MIB47365Medicare UPIN
MIH20426Medicare UPIN