Provider Demographics
NPI:1295905743
Name:MICHIGAN ORTHOPEDIC SURGERY AND REHABILITATION, P.C.
Entity type:Organization
Organization Name:MICHIGAN ORTHOPEDIC SURGERY AND REHABILITATION, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-341-6417
Mailing Address - Street 1:6565 W MAIN ST
Mailing Address - Street 2:SUITE 235
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-6114
Mailing Address - Country:US
Mailing Address - Phone:269-544-4715
Mailing Address - Fax:269-544-4719
Practice Address - Street 1:6565 W MAIN ST
Practice Address - Street 2:SUITE 235
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-6114
Practice Address - Country:US
Practice Address - Phone:269-544-4715
Practice Address - Fax:269-544-4719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041296207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2003984572OtherBLUE CARE NETWORK
MI2576506Medicaid
MI2003984572OtherBLUE CROSS BLUE SHIELD
791203295OtherR/R MEDICARE PIN
B46963Medicare UPIN
0M80330Medicare PIN
MI2003984572OtherBLUE CARE NETWORK