Provider Demographics
NPI:1811151749
Name:ALLEN D DAMSCHRODER MD PC
Entity type:Organization
Organization Name:ALLEN D DAMSCHRODER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-439-8020
Mailing Address - Street 1:4048 CEDAR BLUFF DR STE 1
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8895
Mailing Address - Country:US
Mailing Address - Phone:231-439-8020
Mailing Address - Fax:231-347-6128
Practice Address - Street 1:4048 CEDAR BLUFF DR
Practice Address - Street 2:STE 1
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8895
Practice Address - Country:US
Practice Address - Phone:231-439-8017
Practice Address - Fax:231-347-6128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI430102950207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P02210Medicare PIN