Provider Demographics
NPI:1851580815
Name:SOUTHERN GRAND TRAVERSE MEDICAL
Entity Type:Organization
Organization Name:SOUTHERN GRAND TRAVERSE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHAUB
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:231-995-4902
Mailing Address - Street 1:401 MUNSON AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3041
Mailing Address - Country:US
Mailing Address - Phone:231-995-4902
Mailing Address - Fax:231-932-7816
Practice Address - Street 1:401 MUNSON AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3041
Practice Address - Country:US
Practice Address - Phone:231-995-4902
Practice Address - Fax:231-932-7816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001376363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS56391Medicare UPIN