Provider Demographics
NPI:1659387488
Name:GRATIOT FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:GRATIOT FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL PHYSCIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHESSIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-463-3101
Mailing Address - Street 1:160 E WARWICK DR
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1010
Mailing Address - Country:US
Mailing Address - Phone:989-463-3101
Mailing Address - Fax:989-463-2824
Practice Address - Street 1:160 E WARWICK DR
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1010
Practice Address - Country:US
Practice Address - Phone:989-463-3101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3822220235207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1318641Medicaid
MI2772212Medicaid
MI1336031Medicaid
MI4600404Medicaid
MIB42943Medicare UPIN
MI0B96009002Medicare ID - Type Unspecified
MI0B96009001Medicare ID - Type Unspecified
MI1318641Medicaid
MI0B96009006Medicare ID - Type Unspecified
MI0B96009004Medicare ID - Type Unspecified
MI4600404Medicaid
MI2772212Medicaid