Provider Demographics
NPI:1891809349
Name:MANCELONA FAMILY PRACTICE
Entity Type:Organization
Organization Name:MANCELONA FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:URQUHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-587-9181
Mailing Address - Street 1:PO BOX 769
Mailing Address - Street 2:
Mailing Address - City:MANCELONA
Mailing Address - State:MI
Mailing Address - Zip Code:49659-0769
Mailing Address - Country:US
Mailing Address - Phone:231-587-9181
Mailing Address - Fax:231-587-0923
Practice Address - Street 1:419 W STATE ST
Practice Address - Street 2:
Practice Address - City:MANCELONA
Practice Address - State:MI
Practice Address - Zip Code:49659
Practice Address - Country:US
Practice Address - Phone:231-587-9181
Practice Address - Fax:231-587-0923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI233811Medicare ID - Type UnspecifiedRIVERBEND ID