Provider Demographics
NPI:1295941375
Name:PHYSICIAN HEALTHCARE NETWORK, PC
Entity type:Organization
Organization Name:PHYSICIAN HEALTHCARE NETWORK, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MIMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:CUSUMANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-385-8081
Mailing Address - Street 1:3050 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3819
Mailing Address - Country:US
Mailing Address - Phone:810-385-4441
Mailing Address - Fax:810-385-1540
Practice Address - Street 1:36267 26 MILE RD STE 3
Practice Address - Street 2:
Practice Address - City:LENOX
Practice Address - State:MI
Practice Address - Zip Code:48048-3253
Practice Address - Country:US
Practice Address - Phone:586-716-1371
Practice Address - Fax:586-716-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID