Provider Demographics
NPI:1619192705
Name:LARRY ALTON DO PC
Entity Type:Organization
Organization Name:LARRY ALTON DO PC
Other - Org Name:MONTROSE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:HITCHCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-639-2056
Mailing Address - Street 1:190 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:MI
Mailing Address - Zip Code:48457-9144
Mailing Address - Country:US
Mailing Address - Phone:810-639-2056
Mailing Address - Fax:
Practice Address - Street 1:190 E STATE ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:MI
Practice Address - Zip Code:48457-9144
Practice Address - Country:US
Practice Address - Phone:810-639-2056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007136207Q00000X
MI4704164104363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE26275Medicare UPIN
MIS61532Medicare UPIN
MIOP42680Medicare PIN