Provider Demographics
NPI:1639502701
Name:MERCY PHYSICIAN NETWORK
Entity Type:Organization
Organization Name:MERCY PHYSICIAN NETWORK
Other - Org Name:FRUITPORT FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR PHY REV CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-727-4499
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:231-727-4444
Mailing Address - Fax:231-728-4789
Practice Address - Street 1:3443 FARR RD
Practice Address - Street 2:
Practice Address - City:FRUITPORT
Practice Address - State:MI
Practice Address - Zip Code:49415-8779
Practice Address - Country:US
Practice Address - Phone:231-672-2900
Practice Address - Fax:231-672-2901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-13
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363A00000X, 390200000X
MI363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N28430OtherMEDICARE GROUP PTAN
MI0N33890OtherMEDICARE GROUP PTAN
MI0N33870OtherMEDICARE GROUP PTAN