Provider Demographics
NPI:1336250323
Name:FAMILY PRACTICE OF CADILLAC PC
Entity Type:Organization
Organization Name:FAMILY PRACTICE OF CADILLAC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:CORWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-775-9741
Mailing Address - Street 1:827 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:827 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2015
Practice Address - Country:US
Practice Address - Phone:231-775-9741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080H36303OtherBLUE CROSS BLUE SHIELD ID
MICA0610OtherRAILROAD MEDICARE
MI=========OtherTAX ID NUMBER
MI=========OtherTAX ID NUMBER