Provider Demographics
NPI:1255967667
Name:BLUE WATER INTERNAL MEDICINE, PC
Entity type:Organization
Organization Name:BLUE WATER INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:HACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-662-3505
Mailing Address - Street 1:1210 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3406
Mailing Address - Country:US
Mailing Address - Phone:810-662-3505
Mailing Address - Fax:810-662-3479
Practice Address - Street 1:1210 10TH AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3406
Practice Address - Country:US
Practice Address - Phone:810-622-3505
Practice Address - Fax:810-662-3479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-17
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301076169OtherSTATE MEDICAL LICENSE