Provider Demographics
NPI:1013239185
Name:ELECTRO SPA OF NORTHERN MICHIGAN
Entity Type:Organization
Organization Name:ELECTRO SPA OF NORTHERN MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGUERITE
Authorized Official - Middle Name:J
Authorized Official - Last Name:TILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-933-6001
Mailing Address - Street 1:403 E STATE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-5805
Mailing Address - Country:US
Mailing Address - Phone:231-933-6001
Mailing Address - Fax:231-947-1506
Practice Address - Street 1:403 E STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-5805
Practice Address - Country:US
Practice Address - Phone:231-933-6001
Practice Address - Fax:231-947-1506
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DANIEL M SARYA, DDS, MPH, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1528122207OtherNPI