Provider Demographics
NPI:1336353473
Name:THE BEHAVIORAL MEDICINE CLINIC OF NORTHWEST MICHIGAN, PLC
Entity Type:Organization
Organization Name:THE BEHAVIORAL MEDICINE CLINIC OF NORTHWEST MICHIGAN, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-932-1250
Mailing Address - Street 1:745 S GARFIELD AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3479
Mailing Address - Country:US
Mailing Address - Phone:231-932-1250
Mailing Address - Fax:231-932-1266
Practice Address - Street 1:745 S GARFIELD AVE
Practice Address - Street 2:SUITE C
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3479
Practice Address - Country:US
Practice Address - Phone:231-932-1250
Practice Address - Fax:231-932-1266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010622012080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104467082Medicaid
MI0280237OtherBLUE CROSS BLUE SHIELD MI