Provider Demographics
NPI:1629484290
Name:NORTHERN MICHIGAN ENDOCRINE PLLC
Entity Type:Organization
Organization Name:NORTHERN MICHIGAN ENDOCRINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BASHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KIAMI,MD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-745-6601
Mailing Address - Street 1:1200 WEST NORTH DOWN RIVER RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738
Mailing Address - Country:US
Mailing Address - Phone:989-745-6601
Mailing Address - Fax:989-745-6605
Practice Address - Street 1:1200 WEST NORTH DOWN RIVER RD
Practice Address - Street 2:SUITE B
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738
Practice Address - Country:US
Practice Address - Phone:989-745-6601
Practice Address - Fax:989-745-6605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-03
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063746261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4174554Medicaid
MI4174554Medicaid