Provider Demographics
NPI:1588612972
Name:SIEMER, PHILLIP W (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:W
Last Name:SIEMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:SUTTONS BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49682-0397
Mailing Address - Country:US
Mailing Address - Phone:231-271-5990
Mailing Address - Fax:231-271-5959
Practice Address - Street 1:93 W FOURTH ST STE C
Practice Address - Street 2:
Practice Address - City:SUTTONS BAY
Practice Address - State:MI
Practice Address - Zip Code:49682-8408
Practice Address - Country:US
Practice Address - Phone:231-271-5990
Practice Address - Fax:231-271-5959
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPS051573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1588612972Medicaid
MI4254790Medicaid
MI700D510020OtherBLUE CARE NETWORK
MI700D510020OtherBCBS
MI700D510020OtherBLUE CARE NETWORK
MI0N1951002Medicare PIN