Provider Demographics
NPI:1639223910
Name:EBERT MEDICAL PC
Entity Type:Organization
Organization Name:EBERT MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:
Authorized Official - Last Name:EBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-424-2007
Mailing Address - Street 1:6800 NEWARK RD
Mailing Address - Street 2:STE 300
Mailing Address - City:IMLAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48444-9656
Mailing Address - Country:US
Mailing Address - Phone:810-724-1600
Mailing Address - Fax:810-724-1603
Practice Address - Street 1:6800 NEWARK RD
Practice Address - Street 2:STE 300
Practice Address - City:IMLAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48444-9656
Practice Address - Country:US
Practice Address - Phone:810-724-1600
Practice Address - Fax:810-724-1603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N63080Medicare PIN