Provider Demographics
NPI:1689697930
Name:AUSABLE MEDICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:AUSABLE MEDICAL ASSOCIATES, PC
Other - Org Name:AUSABLE URGENT CARE PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:GERTISER
Authorized Official - Suffix:II
Authorized Official - Credentials:MSN, FNP-BC
Authorized Official - Phone:989-348-7400
Mailing Address - Street 1:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-0393
Mailing Address - Country:US
Mailing Address - Phone:989-348-7400
Mailing Address - Fax:888-821-5005
Practice Address - Street 1:81 S. I-75 BUSINESS LOOP
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-0393
Practice Address - Country:US
Practice Address - Phone:989-348-7400
Practice Address - Fax:888-821-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILH010698207Q00000X
MI5601002890363AM0700X
MI4704159028363LF0000X
MI4704216377363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104563113Medicaid
MI080B010120OtherMD'S & DO'S BCBS GRP #
MI500B010130OtherNP'S BCBS GROUP #
MIS69656Medicare UPIN
S69656Medicare UPIN