Provider Demographics
NPI:1669575148
Name:SUPERIOR WALK-IN CENTER, PC
Entity type:Organization
Organization Name:SUPERIOR WALK-IN CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-387-4220
Mailing Address - Street 1:1504 SAND POINT ROAD
Mailing Address - Street 2:
Mailing Address - City:MUNISING
Mailing Address - State:MI
Mailing Address - Zip Code:49862
Mailing Address - Country:US
Mailing Address - Phone:906-387-4220
Mailing Address - Fax:906-387-5449
Practice Address - Street 1:1504 SAND POINT ROAD
Practice Address - Street 2:
Practice Address - City:MUNISING
Practice Address - State:MI
Practice Address - Zip Code:49862
Practice Address - Country:US
Practice Address - Phone:906-387-4220
Practice Address - Fax:906-387-5449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0800217321OtherBLUE CROSS OF MI
MI3114604Medicaid
MI=========OtherEIN FEDERAL
MI3114604Medicaid
MI=========OtherEIN FEDERAL