NORTHRIDGE FAMILY PRACTICE LLC

Provider Demographics

• NPI: 1891712493
• Name: NORTHRIDGE FAMILY PRACTICE LLC
• Entity Type: Organization
• Organization Name: NORTHRIDGE FAMILY PRACTICE LLC
• Authorized Official - Title/Position: MANAGING OFFICER
• Authorized Official - Prefix: MRS
• Authorized Official - First Name: DEBRA
• Authorized Official - Middle Name: KAYE
• Authorized Official - Last Name: PROVOAST
• Authorized Official - Credentials: RN MSN FNP
• Authorized Official - Phone: 989-728-6000
• Mailing Address - Street 1: PO BOX 279
• Mailing Address - City: HALE
• Mailing Address - State: MI
• Mailing Address - Zip Code: 48739-0279
• Mailing Address - Country: US
• Mailing Address - Phone: 989-728-6000
• Mailing Address - Fax: 989-728-6003
• Practice Address - Street 1: 3190 NORTHRIDGE DRIVE
• Practice Address - City: HALE
• Practice Address - State: MI
• Practice Address - Zip Code: 48739-9276
• Practice Address - Country: US
• Practice Address - Phone: 989-728-6000
• Practice Address - Fax: 989-728-6003
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-07-17
• Last Update Date: 2015-11-02

Provider Licenses

State	License ID	Taxonomies
MI	4301061417	207R00000X
MI	4704173663	363L00000X
MI	4704148660	363L00000X
MI	4704245250	363LF0000X
MI	4704283185	363LF0000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty
No	207R00000X	Allopathic & Osteopathic Physicians	Internal Medicine		Group - Multi-Specialty
No	363LF0000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Family	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
MI	1017859	Other	MCLAREN
MI	105230710	Medicaid
MI	BW148660	Other	BETH WEAVER LICENSE
	MA061417	Other	MOHAMED ALI
MI	RAILROAD MEDICARE	Other	P00261196
MI	4704283185	Other	LINDSEY LICENSE
MI	104289418	Medicaid
MI	105235126	Medicaid
	OC51020	Other	BLUE CROSS BLUE SHIELD
MI	1017858	Other	MCLAREN DEB PROVOAST
MI	DP173663	Other	DEBBIE PROVOAST LICENSE
MI	DD9334	Other	RAILROAD MEDICARE
MI	4704283185	Other	LINDSEY LICENSE
MI	=========101	Other	CCM BETH WEAVER
MI	RAILROAD MEDICARE	Other	P00261196
	MA061417	Other	MOHAMED ALI
MI	1017859	Other	MCLAREN
	OC51020	Other	BLUE CROSS BLUE SHIELD
MI	0P24490	Medicare ID - Type Unspecified	MEDICARE GROUP
MI	0P24490004	Medicare PIN
	MA061417	Other	MOHAMED ALI