Provider Demographics
NPI:1649214099
Name:UPPER MICHIGAN CARDIOVASCULAR ASSOCIATES, PC
Entity Type:Organization
Organization Name:UPPER MICHIGAN CARDIOVASCULAR ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:LEGALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-225-3870
Mailing Address - Street 1:1414 WEST FAIR AVE
Mailing Address - Street 2:SUITE 334
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855
Mailing Address - Country:US
Mailing Address - Phone:906-225-3870
Mailing Address - Fax:906-225-4861
Practice Address - Street 1:1414 WEST FAIR AVE
Practice Address - Street 2:SUITE 334
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-225-3870
Practice Address - Fax:906-225-4861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700E210530OtherBLUE CROSS BLUE SHIELD
0N80080Medicare PIN
MI700E210530OtherBLUE CROSS BLUE SHIELD
0P17990Medicare PIN