Provider Demographics
NPI:1972658136
Name:PRIMARY CARE SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:PRIMARY CARE SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHEPERD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-348-9710
Mailing Address - Street 1:560 W MITCHELL ST
Mailing Address - Street 2:SUITE 340
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2275
Mailing Address - Country:US
Mailing Address - Phone:231-348-9710
Mailing Address - Fax:231-348-9715
Practice Address - Street 1:560 W MITCHELL ST
Practice Address - Street 2:SUITE 340
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2275
Practice Address - Country:US
Practice Address - Phone:231-348-9710
Practice Address - Fax:231-348-9715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074786207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104701069Medicaid
MI104701069Medicaid
MIG65495Medicare UPIN