Provider Demographics
NPI:1790772424
Name:LABERGE, JAMES P (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:P
Last Name:LABERGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2352 HIDDENVIEW LN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48895-9584
Mailing Address - Country:US
Mailing Address - Phone:517-290-7749
Mailing Address - Fax:
Practice Address - Street 1:2352 HIDDENVIEW LN
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895-9584
Practice Address - Country:US
Practice Address - Phone:517-290-7749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010011207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5330086OtherBCBS
MI114456202Medicaid
080177564OtherRR MCR
0N12730Medicare ID - Type Unspecified
MI114456202Medicaid