Provider Demographics
NPI:1750334405
Name:PHYSICIAN HEALTHCARE NETWORK, PC
Entity type:Organization
Organization Name:PHYSICIAN HEALTHCARE NETWORK, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MIMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:CUSUMANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-385-8081
Mailing Address - Street 1:3050 COMMERCE DR
Mailing Address - Street 2:BILLING AND ADMINISTRATION
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3819
Mailing Address - Country:US
Mailing Address - Phone:810-385-4441
Mailing Address - Fax:810-385-1540
Practice Address - Street 1:3350 GRATIOT BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-2121
Practice Address - Country:US
Practice Address - Phone:810-364-4000
Practice Address - Fax:810-364-5995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 207R00000X, 207RG0100X, 207RI0200X, 207RP1001X, 208000000X, 208600000X, 208M00000X, 363A00000X, 363AM0700X, 363L00000X, 363LP0200X, 207Q00000X
MI23D0364244291U00000X
MI363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1750334405Medicaid
MI700G460400OtherBLUECROSS BLUESHIELD
CN1572OtherPALMETTO RAILROAD MEDICARE
MIOG46040Medicare PIN