Provider Demographics
NPI:1932317450
Name:ALLAN D. NELSON, M.D.
Entity Type:Organization
Organization Name:ALLAN D. NELSON, M.D.
Other - Org Name:PENTWATER FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-869-7051
Mailing Address - Street 1:PO BOX 619
Mailing Address - Street 2:500 HANCOCK ST
Mailing Address - City:PENTWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49449-0619
Mailing Address - Country:US
Mailing Address - Phone:231-869-7051
Mailing Address - Fax:231-869-5536
Practice Address - Street 1:500 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:PENTWATER
Practice Address - State:MI
Practice Address - Zip Code:49449-0619
Practice Address - Country:US
Practice Address - Phone:231-869-7051
Practice Address - Fax:231-869-5536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036682261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2107294Medicaid
MI0640001OtherBLUE CROSS BLUE SHIELD
MIB45935Medicare UPIN
MI0640001OtherBLUE CROSS BLUE SHIELD