Provider Demographics
NPI:1356913768
Name:MICHIGAN LIFE MEDICINE
Entity type:Organization
Organization Name:MICHIGAN LIFE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCSWAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-649-2772
Mailing Address - Street 1:496 W ANN ARBOR TRL STE 106
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-6262
Mailing Address - Country:US
Mailing Address - Phone:616-649-2772
Mailing Address - Fax:
Practice Address - Street 1:496 W ANN ARBOR TRL STE 106
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6262
Practice Address - Country:US
Practice Address - Phone:616-649-2772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-14
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty