Provider Demographics
NPI:1598141640
Name:PORT HURON PHYSICIANS MEDICAL GROUP PC
Entity Type:Organization
Organization Name:PORT HURON PHYSICIANS MEDICAL GROUP PC
Other - Org Name:LAKE HURON MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CBO MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BROWN-MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-216-2902
Mailing Address - Street 1:PO BOX 638928
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0669
Mailing Address - Country:US
Mailing Address - Phone:810-216-1884
Mailing Address - Fax:810-216-3025
Practice Address - Street 1:4190 24TH AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3882
Practice Address - Country:US
Practice Address - Phone:810-216-4000
Practice Address - Fax:810-216-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-30
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty