Provider Demographics
NPI:1013095173
Name:LAKE HURON OB GYN PLLC
Entity Type:Organization
Organization Name:LAKE HURON OB GYN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:BISCHER
Authorized Official - Last Name:MACCHIARELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:989-269-3923
Mailing Address - Street 1:1005 S VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-9614
Mailing Address - Country:US
Mailing Address - Phone:989-269-3923
Mailing Address - Fax:989-269-3983
Practice Address - Street 1:1005 S VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-9614
Practice Address - Country:US
Practice Address - Phone:989-269-3923
Practice Address - Fax:989-269-3983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MINK013377207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1653210895OtherBLUE CROSS BLUE SHIELD MI
MI1603210171OtherBLUE CROSS BLUE SHIELD MI
MI4624157Medicaid
MI4645433Medicaid
MI1653210895OtherBLUE CROSS BLUE SHIELD MI
MIN97260001Medicare ID - Type Unspecified
MI0N97260Medicare PIN
MIH75970Medicare UPIN
MI4645433Medicaid