Provider Demographics
NPI:1538123906
Name:NORTHERN MICHIGAN SPORTS MEDICINE CENTER
Entity Type:Organization
Organization Name:NORTHERN MICHIGAN SPORTS MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:231-347-9300
Mailing Address - Street 1:4048 CEDAR BLUFF DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8895
Mailing Address - Country:US
Mailing Address - Phone:231-347-9300
Mailing Address - Fax:231-347-1613
Practice Address - Street 1:4048 CEDAR BLUFF DR
Practice Address - Street 2:SUITE 2
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8895
Practice Address - Country:US
Practice Address - Phone:231-347-9300
Practice Address - Fax:231-347-1613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30617OtherFEDERAL BCBS
MI30617OtherBLUE CROSS BLUE SHIELD
MI30617OtherBLUE CARE NETWORK
MI30617OtherBLUE CROSS BLUE SHIELD