Provider Demographics
NPI:1558709493
Name:CENTRAL MICHIGAN UNIVERSITY
Entity Type:Organization
Organization Name:CENTRAL MICHIGAN UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-953-4002
Mailing Address - Street 1:2981 HEALTH PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-9347
Mailing Address - Country:US
Mailing Address - Phone:989-953-4002
Mailing Address - Fax:989-953-7143
Practice Address - Street 1:2981 HEALTH PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-9347
Practice Address - Country:US
Practice Address - Phone:989-953-4002
Practice Address - Fax:989-953-7143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028129207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104574378Medicaid
0C71067OtherBCBS OF MICHIGAN
MIB46784Medicare UPIN
MI0N84920Medicare PIN