Provider Demographics
NPI:1619997996
Name:THIRD AVENUE FAMILY CLINIC, PC
Entity Type:Organization
Organization Name:THIRD AVENUE FAMILY CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:STAPEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-865-3918
Mailing Address - Street 1:14 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:FRUITPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49415-8920
Mailing Address - Country:US
Mailing Address - Phone:231-865-3918
Mailing Address - Fax:231-865-3510
Practice Address - Street 1:14 N. THIRD AVE
Practice Address - Street 2:
Practice Address - City:FRUITPORT
Practice Address - State:MI
Practice Address - Zip Code:49415
Practice Address - Country:US
Practice Address - Phone:231-865-3918
Practice Address - Fax:231-865-3510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N81350Medicare ID - Type Unspecified