Provider Demographics
NPI:1255519237
Name:NORTHERN MICHIGAN COSMETIC & RECONSTRUCTIVE SURGERY CENTER P C
Entity type:Organization
Organization Name:NORTHERN MICHIGAN COSMETIC & RECONSTRUCTIVE SURGERY CENTER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-487-6070
Mailing Address - Street 1:560 W MITCHELL ST
Mailing Address - Street 2:SUITE 360
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2275
Mailing Address - Country:US
Mailing Address - Phone:231-487-6070
Mailing Address - Fax:231-487-6073
Practice Address - Street 1:560 W MITCHELL ST
Practice Address - Street 2:SUITE 360
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2275
Practice Address - Country:US
Practice Address - Phone:231-487-6070
Practice Address - Fax:231-487-6073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069905207RE0101X
MI43010696042086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE86566Medicare UPIN
MIE57965Medicare UPIN