Provider Demographics
NPI:1295715779
Name:LOWELL FAMILY MEDICAL CENTER
Entity type:Organization
Organization Name:LOWELL FAMILY MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:GAUTHIER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-252-5600
Mailing Address - Street 1:2550 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-8695
Mailing Address - Country:US
Mailing Address - Phone:616-252-5600
Mailing Address - Fax:616-252-5660
Practice Address - Street 1:2550 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-8695
Practice Address - Country:US
Practice Address - Phone:616-252-5600
Practice Address - Fax:616-252-5660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D14845OtherBLUE CROSS BLUE SHIELD
MI0D14845OtherBLUE CROSS BLUE SHIELD