Provider Demographics
NPI:1568630101
Name:MARGARET E GUSTAFSON MD PC
Entity Type:Organization
Organization Name:MARGARET E GUSTAFSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:LUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-845-5992
Mailing Address - Street 1:5 N ATKINSON DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-2918
Mailing Address - Country:US
Mailing Address - Phone:231-845-5992
Mailing Address - Fax:231-843-1931
Practice Address - Street 1:5 N ATKINSON DR
Practice Address - Street 2:SUITE 203
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2918
Practice Address - Country:US
Practice Address - Phone:231-845-5992
Practice Address - Fax:231-843-1931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMG040418174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2748496Medicaid
MI2097699Medicaid
MI2748496Medicaid
MI5530006Medicare PIN
MIB44188Medicare UPIN
MI0533965Medicare PIN