Provider Demographics
NPI:1558616144
Name:GERIATRIC PHYSICIAN STAFFING PC
Entity Type:Organization
Organization Name:GERIATRIC PHYSICIAN STAFFING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:W
Authorized Official - Last Name:SIEMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-271-5990
Mailing Address - Street 1:2700 N SETTERBO RD
Mailing Address - Street 2:
Mailing Address - City:SUTTONS BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49682-9391
Mailing Address - Country:US
Mailing Address - Phone:231-271-5990
Mailing Address - Fax:231-271-5959
Practice Address - Street 1:124 W FOURTH ST
Practice Address - Street 2:
Practice Address - City:SUTTONS BAY
Practice Address - State:MI
Practice Address - Zip Code:49682-9733
Practice Address - Country:US
Practice Address - Phone:231-271-1200
Practice Address - Fax:231-271-5959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051573207Q00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1588612972Medicaid
MIA76072Medicare UPIN
MI1588612972Medicaid