Provider Demographics
NPI:1568640985
Name:HORACE J DAVIS DO PC
Entity Type:Organization
Organization Name:HORACE J DAVIS DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HORACE
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-629-3963
Mailing Address - Street 1:1201 E BROADWELL ST
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:MI
Mailing Address - Zip Code:49224-1474
Mailing Address - Country:US
Mailing Address - Phone:517-629-3963
Mailing Address - Fax:517-629-2198
Practice Address - Street 1:1201 E BROADWELL ST
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:MI
Practice Address - Zip Code:49224-1474
Practice Address - Country:US
Practice Address - Phone:517-629-3963
Practice Address - Fax:517-629-2198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007157208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0851338774OtherBLUE CARE NETWORK
0851338774OtherBCBSM
1005484OtherCALHOUN HEALTH PLAN
100019OtherGREAT LAKES HEALTH PLAN
MI1917979Medicaid
E25963Medicare UPIN
100019OtherGREAT LAKES HEALTH PLAN