Provider Demographics
NPI:1639162589
Name:GRAND TRAVERSE SURGERY P.C.
Entity Type:Organization
Organization Name:GRAND TRAVERSE SURGERY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROCHE
Authorized Official - Middle Name:J
Authorized Official - Last Name:FEATHERSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-935-8890
Mailing Address - Street 1:701 W FRONT ST
Mailing Address - Street 2:STE 200
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2287
Mailing Address - Country:US
Mailing Address - Phone:231-346-4023
Mailing Address - Fax:231-932-7311
Practice Address - Street 1:701 W FRONT ST
Practice Address - Street 2:STE 200
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2287
Practice Address - Country:US
Practice Address - Phone:231-346-4000
Practice Address - Fax:231-932-7311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP43453Medicare UPIN
MIG31413Medicare UPIN
MIH01374Medicare UPIN
MIH32153Medicare UPIN