Provider Demographics
NPI:1851671697
Name:TRAVERSE OBSERVATION PHYSICIAN SERVICES PC
Entity Type:Organization
Organization Name:TRAVERSE OBSERVATION PHYSICIAN SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:EVELYNE
Authorized Official - Last Name:KAEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-947-0673
Mailing Address - Street 1:4624 N SPIDER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-8440
Mailing Address - Country:US
Mailing Address - Phone:231-947-0673
Mailing Address - Fax:
Practice Address - Street 1:1105 6TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2345
Practice Address - Country:US
Practice Address - Phone:231-947-0673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI001OtherPRIORITY HEALTH