Provider Demographics
NPI:1265729883
Name:PHS OF MICHIGAN PC
Entity type:Organization
Organization Name:PHS OF MICHIGAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STATE MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CODY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-827-3200
Mailing Address - Street 1:6452 MILLENNIUM STE 100
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-7881
Mailing Address - Country:US
Mailing Address - Phone:800-207-9419
Mailing Address - Fax:
Practice Address - Street 1:1780 E PARNALL RD
Practice Address - Street 2:PARNALL CORRECTION FACILITY- MEDICAL CLINIC
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-7136
Practice Address - Country:US
Practice Address - Phone:517-780-6393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-03
Last Update Date:2011-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094288261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center