Provider Demographics
NPI:1902817984
Name:SUPERIOR FAMILY MEDICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:SUPERIOR FAMILY MEDICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAHN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:906-632-0370
Mailing Address - Street 1:550 OSBORN BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1899
Mailing Address - Country:US
Mailing Address - Phone:906-632-0370
Mailing Address - Fax:906-632-2081
Practice Address - Street 1:550 OSBORN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1899
Practice Address - Country:US
Practice Address - Phone:906-632-0370
Practice Address - Fax:906-632-2081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJP04613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2114539Medicaid
MI0170005Medicare ID - Type Unspecified
MI2114539Medicaid