Provider Demographics
NPI:1578547071
Name:NORTHERN PINES HEALTH CENTER, PC
Entity Type:Organization
Organization Name:NORTHERN PINES HEALTH CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITZIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:HEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-269-4185
Mailing Address - Street 1:11293 N M 37
Mailing Address - Street 2:SUITE A
Mailing Address - City:BUCKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49620-9593
Mailing Address - Country:US
Mailing Address - Phone:231-269-4185
Mailing Address - Fax:231-269-4461
Practice Address - Street 1:11293 N M 37
Practice Address - Street 2:SUITE A
Practice Address - City:BUCKLEY
Practice Address - State:MI
Practice Address - Zip Code:49620-9593
Practice Address - Country:US
Practice Address - Phone:231-269-4185
Practice Address - Fax:231-269-4461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X
MI5101013101305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4513149Medicaid
MI233937Medicare ID - Type Unspecified
MIG94472Medicare UPIN