Provider Demographics
NPI:1548422462
Name:AMBULATORY CARE CLINIC OF IONIA PC
Entity Type:Organization
Organization Name:AMBULATORY CARE CLINIC OF IONIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-522-9110
Mailing Address - Street 1:3015 S STATE RD
Mailing Address - Street 2:
Mailing Address - City:IONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48846-9416
Mailing Address - Country:US
Mailing Address - Phone:616-522-9110
Mailing Address - Fax:616-522-9114
Practice Address - Street 1:3015 S STATE RD
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-9416
Practice Address - Country:US
Practice Address - Phone:616-522-9110
Practice Address - Fax:616-522-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063290261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4118690Medicaid
0M882210Medicare PIN