Provider Demographics
NPI:1336194166
Name:GRAND TRAVERSE WOMENS CLINIC PLLC
Entity Type:Organization
Organization Name:GRAND TRAVERSE WOMENS CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:P
Authorized Official - Last Name:MADION
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-392-0650
Mailing Address - Street 1:1200 6TH ST
Mailing Address - Street 2:STE 400
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2369
Mailing Address - Country:US
Mailing Address - Phone:231-392-0650
Mailing Address - Fax:231-392-0665
Practice Address - Street 1:1200 6TH ST
Practice Address - Street 2:STE 400
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2369
Practice Address - Country:US
Practice Address - Phone:231-392-0650
Practice Address - Fax:231-392-0665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N30860Medicare PIN