Provider Demographics
NPI:1689321010
Name:ORTHOPEDIC SPORTS MEDICINE OF MANISTEE PLLC
Entity Type:Organization
Organization Name:ORTHOPEDIC SPORTS MEDICINE OF MANISTEE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:917-545-0789
Mailing Address - Street 1:3234 COUNTY LINE RD W
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-9519
Mailing Address - Country:US
Mailing Address - Phone:917-545-0789
Mailing Address - Fax:
Practice Address - Street 1:3234 COUNTY LINE RD W
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9519
Practice Address - Country:US
Practice Address - Phone:917-545-0789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-05
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty