Provider Demographics
NPI:1780803932
Name:NORTHRIDGE FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:NORTHRIDGE FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVOAST
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:989-728-6000
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:HALE
Mailing Address - State:MI
Mailing Address - Zip Code:48739-0279
Mailing Address - Country:US
Mailing Address - Phone:198-972-8600
Mailing Address - Fax:989-728-6003
Practice Address - Street 1:3190 NORTHRIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:HALE
Practice Address - State:MI
Practice Address - Zip Code:48739-9276
Practice Address - Country:US
Practice Address - Phone:989-728-6000
Practice Address - Fax:989-728-6003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061417207R00000X
MI5101011670207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMA061417OtherMOHAMED ALI
MIDL074550OtherDANIEL LEE
MI104289418Medicaid
MI114811801Medicaid
MI080C510310OtherBCBS GROUP
MIMA061417OtherMOHAMED ALI
MIH22803Medicare UPIN
MI0P24490Medicare ID - Type UnspecifiedGROUP
MI114811801Medicaid
MIMA061417OtherMOHAMED ALI
MI104289418Medicaid