Provider Demographics
NPI:1245280130
Name:NIEMI, PHILLIP W (DO)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:W
Last Name:NIEMI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:550 OSBORN BLVD
Mailing Address - Street 2:SUITE #202
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1899
Mailing Address - Country:US
Mailing Address - Phone:906-632-1100
Mailing Address - Fax:906-632-7768
Practice Address - Street 1:550 OSBORN BLVD
Practice Address - Street 2:SUITE #202
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1899
Practice Address - Country:US
Practice Address - Phone:906-632-1100
Practice Address - Fax:906-632-7768
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101008398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2120652Medicaid
MIE26499Medicare UPIN
MI5170013Medicare ID - Type Unspecified